Dillon, Jean r-rO OF QUEE B 21
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
_ Funeral Director
Name J e4n ��); fI0ti
Case#.
Date Of Cremation p7
Time Cremation Started 7: 30 M
Time Cremation Completed
Type of Container 4r4�a� C�w��� SST 5^
Remarks
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To"of Queewnsbury
Pine View Cam lery and Crem8kXiwm
21 Quaker Road,Queensbury, Now York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authortaes Plne View Cremeftium,In accordance with and subJed to ks Rubs and Regulations to
cremate the remains at
Jean Elizabeth (Morse) Dillon F
(Name) (SOX)
325 Broadway Apt. 46 Fort Edward NY 12828-
(Stneet) (City (Swe) (7J p Code)
who died on 20th day of September 2007
at Glens Falls Hospital Glens Falls NY
(Place) (Address)
Name and address of on met living relative or name of person sudxxb y cwematlon:
Martha M. Dillon 12 Charles Street, South Glens Falls, NY 12803
(Name) (Address)
Retati0r>Ship Io the dacaaeed Daughter
Nameof Funeral tionre Carleton Funeral Home, Inc.
IMPORTANT:
I repraw i that to the best of my Iarowledge,the deceased(hw)or(has no)pecernalw,def iAla r,battery,battery pads,power
cell,radioactive implant or radioactive device M his or her body.(Ckde one)
l owtily that i have fiA power and suthorlmtion to anarW forgo cremation of the remains and to dhea the disposition of the
crarttatad ,MW any peraoneel poeaessions have either been removed or maybe dawayed,and agree to prdect,defend and
save View Crams rium from arty and all claims and demmids for rose or demages wftleh may be made agoneet Stem
by the cramatfon of acid r�emaks es di ecled,vrheltter such dabns or darnands are or ere not wholy
68 Main Street, Hudson Falls, NY
_ 7
fthis
12 Charles Street,.SSoouth Glens Falls, NY 12803
( R Relative or t egar Representative)
ate:
Disposition of Cremated Remains j
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I hereby direct Pine View Crematorium to Hap oee of the cremated remains as fioilowa:.
Mail to
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Other arrartgemem-Please specify:
if pulveraNion of cremated remains is requested,check here XX
rtevision:April 18,2007 j
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