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CEMEr Ry AND CREMATORIUM
QUtiSCP�t ROAD, QIJEpNS$URY tYLW YORK 128o4
(518) 745.4-476 (518) 745'.4477
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Town of Queens"
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Offte: (518)745-4476, Crematorium: (518)745-4477
Auttrorization to Cremate
The undersigned raquests and aumorims Pine View ownworium,in acoorderwe with and subjed to Its Rubs and Regulations to
cremate the remetns of
Kevin Wayne McCarthy, Sr. M
(Name) (Sent)
2.33 Broadway Fort Edward NY 12828-
(Smeet) (CRY) (SUM) (Wp Code)
%Ao died on 3 0 t h day of July 20 0 7
at Residence Fort Edward NY
(yam) (Address)
Name and address of neareet Nvbhg nhl00 Or name of person ahlhorlsing aernabon:
Alice McCarthy 233 Broadway
(Name) (Address)
Releboraft to the deceased W i f e
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the bed of my larowiedge,the deceased(has)oimeker,deftrilletor,battery,battery pack,Powell'
oW,reatecdve krgft t or radioactive devbe in his or her body.(Gkriv One)
I our ify that I have fill power and audwrbatlon to ammgs for the o9m@*n of the remains and to direct the dispoeklon of the
crenm*W rernairna,that any personnel p-Q a 4 4ions have ONO been removed or maybe destroyed,and agree to prated,defend and
gave hwwftaa Ptne View CromaftrWm from any and al ddms all damardr s for bse a carriages whidi maybe made apaine4 d wn
by reason of or cunnacmd vdh tin cremation of add remains as dibcfed,whedwr such dab, a dm-a ds are or are not wimly
groundless,false or freudtft%. .
44
68 Main Street, Hudson Falls, NY
4 4�(W9tness) IAddresa)
a
233 Broadway
(Signstue and Address of or Legal Represw tW)
Signed on this date:
Disposkion of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the c ameted remains as bNows:.
Mail to
other arrsngernem-Please specify:
if pulverization of cremated remains is requsated,check here XX
R&vlsim.April 18,2007