Nichols, Marion T07tiN OF QUE
PINE V'EW CEMETERY AND 'CREMATORIUM
QUAKER ROAD
QUEENSBURY, NEW YORK 12804
(518) 745.4476 (518) 745'.4477
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Funeral Director
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Date Of Cremation i -
Time Cremation Started
Time Cremation Completed
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Town of Queensbury
Pine Yew Cemetery and Crematorium
21 Quaker Road, Queensbury,New York, 12804
Cemetery Office:(518)745- 476,Crematorium;(518)745.4477
Authorization to Cremate
The undersigned requests and authorizes fine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains oF.
Marion Elizabeth Nichols F
(Name) (SOX)
17 Pearl St. , Apt. HLdson Falls NY 12839-
( ) (city) (fie) (Zip Code)
who died an 24th day of Jan 20 07
at Glens Falls Hospital Glens Falls NY
Place) (Address)
Name and address of neerost wing reiativs or name of person aulhorh*V cremation:
Lawrence Nichols 10 Shallow Creek Rd, Queensbury, NY
(Name) (Address)
Relatimiship to the deceased S o n
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the bast of my lawwledge,the deceased(has)or(has no)paoarnalaar,dei brl atom or any other battery operated
device in his or her body. (Cicle One)
I certify than t have full power and authorization to arrange for the cremation of the remains and to direct the dbposftn of the
cremated remains,11h t any personal possessions have either bean removed or may be deapoyed,and agree to protect,dellend and
save harmless Pine View Crematorium bom any and all clskns and demands for loss or demages whit►maybe made apeinst them
by Of Or amnKMd wkh fhe cremation of said remains as directed,whadver such datums or demands are or are not wholly
false or
�� Carleton Funeral Home, Inc.
7—�
(YVkrmass} (Address)
10 Shallow Creek Rd. , Queensbury, NY 12804
(Signature and Address or Low Represanc aj
Signed on this date: Jan. 28, 2007
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated mated n'eam"as 110111OWS:
Man to
Other arrarvemerets-Please specify:
If pulverization of cremated remains Is requested,chat*here XX
Revision:January 1,2006