Ryan, Thomas OT QUEE-�) 523UT_T
PINE YIEW CEMETERY AND CREMATORIUM
QU R ROAD, QUBENS6VRY, N-EW YORK 128D4
(518) 745.4.476 (518) 745.4477
Funeral Director
NameI
Cased 2tlU
Cremation
^ e Cremation Started
Te Cremation Compjeted
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Town of Queettsbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Ofkm: (518)7454476, Crematorium: (518)745-4477
Audwization to Cremate
The undersigned requm tr and autltortms Pkte View Crematorium,in aacordencewith and sul*d to Its Rubs and Regulations to
cremate the rerneirte ot:
Thomas Ryan M
(Name) (Sere)
Chateau Drive, Clifton Park, NY
(Stn3et) (City) (SWIS) (ZJp Code)
whodiedon The 6th days uru. 20.�LL
at Glens Falls Hospital Glens Falls NY
(Place) (Address)
Name and address of rhfr- m living ntU9"or name of person authabnp crematlam
DNG�tN C. `IIC -
( ) (Addmm)
Relatiortshfp to the deceased
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
l ralxesent that to the beat of my Wvwk dg%the deaeesed(has)a aker,de4lbriN W,battery,boary ice,power
call,malomcdve implant or radioectIve device in his or her body.(Cirde )
i oerWy dig I here rhd power and sutlhorkadon to arrange for ilia asmadon of the remalne end to dkect the disposition of the
cremated remains,that any personl posesesknu have ell w been removed or may be destroyed,and apse to protect defend and
rive Charmless Pine Wow Cremefttsrt from any and ON ciaitos and demands U bgds or damages which maybe made agalnat them
by reason of or cartec led wink the cremation of add rev aka as directed,whether mxb dab, or demands are or are not wholly
gmund*W false
7,7t
68 Main Street, Hudson Falls, NY
(Sipnatrxe end AddFeffi Of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Ramalne
I hereby direct Pine Vlew Crematorium to dispose of the cremated remains as foHovvs:.
Meal to
outer arrahpamente-Please,spew-
tf puiverketion of cremated ntrnaim is rued,check here XX
Revision:April 18,2007