Moumblo, Mary OF QUEENs5BUP
PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QLjEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �c,P�r{o`
Name 1w,do
Case# 3NS"
Date Of Cremation
A 2oU7
Time Cremation Started 7' -q A
Time Cremation Completed 0 :0C,
Type of Container IT �94, �� IST (/4
Remarks
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I
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Town of Queensbury
Pine View Cemetery and CremaWum
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Aud xtzadon to Cremate
The urrder=ignsd rwpm is and&Axxlms P'km View crenteorkim,In eeoorderroe with and subject to ks Ruks and Roguletlons to
aerrtete the remains d:
Mary Jane (Forth) Moumblo F
(Name) (S")
Pleasant Argyle NY 12809-
( ) (spy) (state) (7J p Code)
who died on daYof 08/08/2007 24_
at PLEASANT VALLEY NURSING Argyle NY
(Pk") ( )
Nome and oddMW d nearest IMM reWa or name of person arrtltorb*V oerrnAlon:
Mrs. Lester Moumblo 10 Fourth Street
(Name) (Address)
Reiatlortelrip to the deCe99ed S on
Carleton Funeral Home, Inc.
Name d Funaai Hoare
IMPORTANT:
I represent that to the best of my lawaledge,the deceased(has)or(Free no)peomyoker,deRdIllator,bette y,battery Pack.power
cep.redloecolve implant or raflosc Ove device In his or her body.(Cl de One)
d to
i ramify that 11 fill power and nW o sees l r hh wee ON in been mm� vedremoved or may d ub eyed,errd taprae to prolea defend and
aamraeed rerrreirrs,tl161 any Personal poeaessiorte
seas hamdeae Ppp View Cremetorium from arty and all chime and demands for bw ar deRu ges wtdch may be made age!rrei than
by reason of ttN criNnU M of add FORM"as dk eeled,whedw arch dab. or do s are or are not wholly
r:
68 Main Street, Hudson Falls, NY
(After)
10 Fourth Sri
(Sipnaturo srrd Address of Retetive or Legal Reprownti m)
Signed on this date: 141�� - D O )
Dbpoekion of Cremated Remekte
I hereby direct Pine View Crerralorkn to depose of the aemreted remains ea fo 0".
Mail to
Outer arnwK"W N"-release spedfy:
if pulveraetion of cfemaled msmekw is requested,dre*two XX
Revwian:April 18,2007