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Campp, Mildred
TO Y 03� OF QUEEN,5BU- y PINE YlEw CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSgURY NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name ,i — =+� t� (I u� I i "o(I (.I i Case#. Date Of Cremation �6L(r I Time Cremation Started Time Cremation Completed 6 - so Type of Container c,rclboc�, RemarksF C©cL . n -------------- i Town of Queectsbury Pine View Cemetiery and Crematorium 21 Quaker Road,QweensWry, New York, 12804 Cemetery Office: (518)745-4476, Crematorium: (518)745- 477 ' Audioriiadon to Cremate The undersigned requite and aAhoritss Pine View CrerltaAmorlurn,In sacordence with end&"vot to Its Rules and Regulatbr a to cremate the renw"d: Mildred Evelyn (Wrye) Campp F (Neste) (SOX) 8.4 Boulvard Queensbury NY 12804- (Strt3et) (CNy) (St") (ZJP Code) who died on dayd 12/03/2007 20_ at Glens Falls Hospital Glens Falls NY (PIRM) ( ) Name and eddnm d nearest IWIng reietlre or itarrte of person autttorhng C mnetkmn. Mr. Jeff Campp 15 Park Ave. (Nww) (Address) RaetiortOV to the deceased S o n NamedFuneraiFiarre Carleton Funeral Home, Inc. IMPORTANT: l represent that to the best of m y kv7*iedge,the deceased(his)�_nnjjreoertieker,dei46riNatar,bettmy,battery peck,power ceN,r�edkwcetve impish or=Noactive device in his or her body.( '0r1Vr I ow*I"I hen u power and eudwrtredon to am ingg for the a+ematbn of an remains end to dWW the deposition of the aamated rernstrts,that ant►peFoonel Pew have aietex baen removed or may be fig,e0 fly ed,and agree to P1y.defend and move hermiew Pine View C unstoritsn from any and 08 deki and denimmis for bw ar dwneges which may be made epelllst them by reemvrt d or connected wllh the cremation of add tetink 85 drected.whedw rich r iairtta or dartterrds are or ete not wholy qroundkwv, fain 68 Main Street, Hudson Falls, NY gftrA=) (Aftws) 15 Park Ave. (SW4&e and Address of Rob"or L%W Repreeentetive) Signed on this date: DispoeMw of Cremated RemaMe I hereby direct Pine View Crematorium to dispwe of the cremated remains as*Mows:. Mail to Other arrangements-Piaaee epw*r. if pulm&Vion of awnatsed mmem is mweseed,dw&here XX Revfs "..AprN 18,2007