Cervone, Vincent Y
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PONE YIEW Q,�rE��8 l.-L
CEMETERYCREM�TORiVM1
QUNCfst ROf,D, QUHENSHVRY
(518) 745.4.476 K8W YORK 128N
(S18) 745',4477
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Town of Queerisbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745.4476, Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and M010 iws Pine View Cremetorlum,in accordance with end subject to its Rules and Regrhlatbms to
cremate the remains of:
Vincent Carl Cervone M
(Name) (Seek)
8.9 Pearl Street Hudson Falls NY 12839-
(Stneei) (City) (State) (Zip Code)
w1v died on day01 07/09/2007 20_
at 89 Pearl Street Hudson Falls NY
(Plem) (Address)
Fame and address of 'a m as itvkmg rely"or name of person authorb*v cremation:
Mrs. Christine Murphy 89 Pearl Street,
(Name) (Address)
RaWtignship to Daughter
NimeofFunerellkno Carleton Funeral Home, Inc.
IMPORTANT:
l represent that W tf to best of my lawwledg%the deoeaaed(hes)or(has no)Pacemaker,defibrillIeW,betoerY,betwY per,power
ceN,radio c&*imptard or nKWoective devimx in fta or stir Hody-(Girds One)
1 aer*fief I#revs AM power and wi torimtlon to arrange for the c rermasgon of dw renwWrts end to direct the disposition of the
cremated remains,that any personal poseessions have either stain removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crerimelorlurm from arty and ali cl>lims and demands for im or damages which may be made against tltem
by mown of arcorrtWM wkh du cremation of add remains as dk eded,whether such alai ns ar danrarrds are or era not wholy
'orftau*Aeni 68 Main Street, Hudson Falls, NY
r ) (Addross)
89 Pearl Street, Hudson Falls, NY
(Signatue end Address of cr Legal RepresernatIve)
Signed on this date:J u �1/ �/, 9-0 O ;-
Disposition of Cremated Remains
I hereby direct Pine View Crematorkim to dfspoee of the cremated remains as foNows:.
Mall to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here XX
Revision:April 18,2007