Corsones, George r
Qu rE rE 9�,5
,
PINE nEW CEMETERY A1YD CREMATORIUM
ROAD, Ql1EENSBVRy, .. YORK 12804
(518) 745.4-476 (518) 745'•4.477
7 Fvneral Director
Casein
-ase 0 ! Cremation jUNL � S
^ e Cremation Started
_ la -ub .pM
^ e Ctematton Completed 3:vo p
;e o ! Container
remarks
.��1 I�'•'SU
Ca0(. uN P
Tom of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Roast,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477 '
Aud xxtzedon to Cremate
The uidersigned raqueats and aullwtzes Plrre View Crematorium,In accordance with Brad subject to b Ruka and Regulations to
cremate One remains ot~
George Corsones M
(Name) (Sex)
Meadowbrook RoacUueensbury NY 12804-
(Stneet) (City) (State) (7J p Code)
wft died on the 23rd day of June 20 7
at Glens Falls Hospital Glens Falls NY
(Place) (Address)
Name and address of nme sat livhrg relative or name of per Om surdxw rirag cremation: �p
nLAJJ1:t- K V,_ C yr � 10 Y'(1��1e l� I�Qq�+ OLAAVCA'
(Name) Address)
ReietlorWM to the deCaaaed Daughter
Name of Funeral tior, Carleton Funeral Home, Inc.
best
IMPORTANT: oemdcer,de�etor,battery,battery peck,power'
E represent did to the of my imvwladpe,the deceased(ttas
call.rsdioacd"implant or radkxwdve device in his or her body.(Glide One)
I ow*Chet I have Ul power and auftwbmdon to arrange for the cremation of the remains end to direct the dispoaltl m of to
cremated remains,that any personal possessions have eMwm been rs"Kwad or may be destroyed,and agree to protect,defend and
save harts n Pine View CremaWr4rtrr from any and all claims and demands for bale ar damages~may be a ads agalrat them
by mown of or connected wish the crwnadm of add n omen es d rected,whether such debits ar derrrends are or ere not wholly
groundless,false or
° 68 Main Street, Hudson Falls, NY
y hmv�&-q—L
(Signature/and Address of Reladvelor Legal ReprasereatMe)
Signed on this date: O '/_ O
Disposition of Cremated Remains
I hereby d rec Pine View Crem&Wiurn to dispose of the aemated remains ae folow$'
Mdl to
Other arrangements-Please specify:
if pulverization of Cremated remains is requeeted,d w*here XX
Revision:April 18,2007