Gregorio, Theresa OF QUEEN,5BU-r�y
PLNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURY, NEW YORK 12804
(518) 745-4476 (518) 745--4477
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Funeral DirectorRLE7y,0
- Case# St(�
Date Of CremationAf a%—
Time Cremation Started
Time Cremation Completed
Type of Container Wvu�p CA L"', -IrF
Remarks
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MOVE.
coop ��. Do 2h
Tom of Queerm"
Piro View Ceff ewy and Crematorium
21 Quaker Road.Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Audwdzadw to Cremate
The undwWgned requests and auMt ears Pk*View CrenvAo lum,In aacwdencewkh and pAjed to Its Ruin and RegrrMbns to
cremate the remeft d:
Theresa B. (St. Louis) 6y, F
(Name) (Sex)
6 Devine Kingsbury NY _
(Striae) (City) (State) (7J p Code)
vdto died on day of 12/18/2 0 0 7 20_
at Residence Kingsbury NY
(PIece) ( )
Helmand address of nearest living mietYNlt or Hama d poison aLeWrbft ae n0m
Dh�lr 5 le��ti X Mo--%+L-`V". GI�i Its rvY <Z O
��(Nartre) (Address)
P4wMerewtode
Nam d Funeral Home Carleton Funeral Home, Inc.
IMPORTANT: e dicer,�,betto y,bey pK.pmw
E represent that to the beet of my iagwledge,th deoeasad(tree)
aA,nKfkwc&40 Inq tent or radinecdva detirfoe in his or her body.( )
1 sanely that I have IRA powx and audwrtaidon to anange for the aemedw of the remake and to dVwt the depOWW of the
cremated remakrs,that any personal possessions have eiMfar bean ramwed or may be deal!Dyad,and agree to proled,defend and
sem henttleos Plus Maw oWoorb"fmm arty and aM dsims and der wKW for sties ar rIN ages whldt may be trtade a go" qt them
by Fesson d or oo acted wNh tM cremation of add ratnelns as dkected,whndtar atrclt dak i or de 'a jA are or ere nM whoNy
7� it�se ar�ydulent
��--.�'1 68 Main Street, Hudson Falls, NY
�G'
and Address of Reledw or Legal )
Sgned on this date: �4LL
DEeposib W of Cremated Rename
I hereby dked gyre View CrenwWrirxn to dispaae of flue cremated remake ea toNows:.
mom to
Other arrwver wit-Plisse sireclN:
tf puwer¢stion of aim ftd remains is regt)eaed,dye&here XX
Revisiarr April 18,2007