Dickinson, Nancy QU E E 9�r,5 B U T�
PLNE nEW CEMETERY AND CREMATORIUM
Q�AK�—R ROAD, Q(JEg,NSBj_rRY. NEW YORK 12604
(518) 745.4476 (518) 745.4477
Funeral Director
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Tom of Queensbury
Pine View Cemetery and Crematarium
21 Quaker Road,QueensWry, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477 '
Authorization to Cremate
The undaraigned requests and audmrtaes Pine View Crematorium,In accordance v fth and subJsct to Its Rules and Regulations to
cremate the remains of:
Nancy Dickinson F
(Name) (Sex)
8 Keating Ave. Fort Edward NY 12828-
(Strest) (City) (Slats) (7Jp Code)
v"disdon the loth day of June 2007
at Residence Fort Edward NY
(Place) ( )
Name and a nag of ilvbrg r*Ww or name of person autlwrbnp crema0m
A ,
(Name) (Address) -
Reletiortship to to deceased b a V1 0
Nemed Funeral 11cme Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to tha beat of my lawwledge,the deceased(has) pscemsker,defib folor,bettarY,betierY peck,pa'
call,redloective irrrpW or radioaCOW levios M tse or her body.( )
I ow*first l have full power and sudwrIzetlon to arrange for Ma cremo ko of the remains and to direct the disposom of the
Crap ramalna,do any pereoned posesesbm have eNa teen removed or may be destroyed,and agree to prdeGt,defend and
gave twmiass Pine View Cnamakviu m from arty and all claims and demorKb for loss ar damages Mritisft maybe made ogwld vsm
by reason af or corstecied wilt kM c rvmeVm of said remains as directed,whether such r1al s ar dwnards are or are nU wholly
#ft% ss,false or*Mxkmt.
68 Main Street, Hudson Falls, NY
IL Vl Qom , (+ )
(Signature end Acfdrees of RelatNe or legal Repreaer tine)
Signed on this date: y Lt n c I I J oZ o 0 7
Disposition of Cremated Refrains
I hereby direct Pine View Crematorium to disease of the cremated remains as follows:.
Mail to
Other arrangarnerrts-Please specify:
If pAver¢ation of Cremated remains is mwested,dreck here XX
Revisicur:April 18,2007