Schermerhorn, Ruth P LN E QU
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LNE V E:Vy p MET1rRY AND CREMATORtU.
QUEeNSeVRY
(S18) 745,4476 NEW YORK 17804
(S18) 745.,4.477
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Town of Queensbury
Pine View Cemetery and Cr+emetadum
21 Quaker Road,Queensbury, New York, 12&9
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
AudXmizedon to Cremate
The uhdsrsigrred requests and aulh dZw Pine View CnemMm um,In accordencewith and wAjad to its Rules and Regubtiom to
c rarnate the remains of:
Ruth Schermerhorn F
(Haute) (Sex)
7. Culvert Street Glens Falls NY 12801-
( ) (City) (Swe) (7Jp Cam)
wft died on day01 07/11/2007 20
at Glens Falls Hospital Glens Falls NY
(PIece) ( )
Name and address of rn— me IMM relerAra or name of person euthorb*V Cmma m:
Heidi Schermerhorn 143 1/2 John Street, Hudson Falls, NY 12839
(Nam) (Address)
Relationship to the deceased Daughter
Name of Funeral Fiome Carleton Funeral Home, Inc.
IMPORTANT:
I reprasent that to the best of my lawwledge,the deoeasad(has)or(Frey no)paoen dw,delibrillietor,battery,battery pact,power
cell,radloective implant or tadioactive device In We or her body.(Cirde One)
I certify that I have U powar and autluxtmdon to ananpo for the c remadon of the remakhs end to direct the diepoaslon of the
cremated remains that any personal possessions have either been ramoved or may be desboyed,and agree to prdect defend and
save hermlep4lffie View Crwen et Asw from any and all Gaims and demands f or ioss ar dsmapas which maybe made against them
by n3eav or c ed crametion of said remains as directed,whether such claims ar der'a ds are or ere nat wholly
68 Main Street, Hudson Falls, NY
(Address)
143 1/2 John Street
(Signature and Address of Relatkv or Legal Representa lve)
Signed on this date: 7 /.2 v
Disposition of Cremated Remains
I hereby died Pine View Crematorkhm to dispose of the memeted remains as follows:.
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is mWested,dw&here XX
RevWxt April 18,2007