Dashnaw, George Sr. L O`T''N OF QUEE9�5BU-r�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBLMY NEW YORK 12804
(518) 745-4476 (518) 745-4-477
Funeral Director 6<1)tfC,
�
Name C eo�C� pr,5� , Sl ,
Case#. _ tjjc
Dace Of Cremation UC-10 3v
— - f Zo
Time Cremation Started
Time Cremation Completed 2 �6
Type of Container I d
Remarks
oc/ i2 2 s P
33
° P�
Town of Queansbury
Piro View Cemetery and Cremakftm
21 Quaker Road,Queensbury, New York, 12804
Cemetery Ofk a: (518)745-4476, Crematorium: (518)745-4477
Audxxlzabon to Cromte
The underslgrad requests and auu,ortm pkw View Cren oodum,in aocordanm with and subject to its awes and Regulations to
cremse the remains at
George Ernest Dashnaw, Sr. M
(f,arnel) (Seek)
1.5 Jamaica Moreau NY 12803-
(Sb1w) (C" (btata) (Zip Code)
who died on day 10/25/2007 24at _
Residence Moreau NY
(Place) (Address)
Now and adk7rtKs of nearest%*q rttlethna or named person attttortdng aemertiort:
Mr. Ernest Dashnaw 15 Jamaica Ave.
(Name} ( )
Relellon0lip 10 the deceased S o n
Carleton Funeral Home, Inc.
Name d Funeral Horne
IMPORTANT:
I repraeent that to the beat of my knowledge,the deceased(has)or im no)Pacemaker,deffbriMetor,battery,battery Peck,taw
cell,rsdloac o"intlA Mtt or nKNoscow device In his or her body.(Circle One)
I ow*that I ton fwl power and @uax rtsetlon to ananga for the cretttetion of the rerrtakts and to direct the ksspo Ntlon of the
crane tad remains,that any pereortal posenskww have eM mm'heart removed or maybe deft eyed,and agree to protect,defend and
save han"feas Pkw New Cramebmium from any and all k lairma and demands for boa or damages~may be made agttira1 them
by raqwn for cmwmcwd wMh the cramadon of said nanw*s as dimled,whedw such claims or denterrds are or are trot wholly
knL
/t1��— 68 Main Street, Hudson Falls, NY
ajzdnt15 Jamaica Ave l '5. tK t'o )e+tS
(Signamme w4 A,d*es offielvam or Legal Reprewm4a hre)
Signed on this date:���� L C) U
Oispo loon of Cremated Remains
I hereby direct Pine View Cremaloriurn to dispose of the aemated rernalm as toNOwa:
malto
Other arrangonm ift! -Please =
if pulverdation of cremated remains is mWesled,dock Fare XX
Reviskne April 18,2007