McIlvaire, Florence OF QUEE9�,(50u ��
PLNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORY 1284�
(518) 745-4476 (518) 745-4-477
r Al ?Funeral Director_
Name— (� IUP�►1CP M C I 104
_Case# 70
Date OF Cremation 0 %
T =me Cremation Started SG M
T :me Cremation Completed
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12844
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477 '
Authorization to Cremate
The undersigned requests and a 9mrlaes Pk*View C TwWarlum,In a000rdenoe with end subjed to Its Rules and Regulations to
cremate the remains ot:
Florence Webster McIlvaine F
(Name) (Sex)
2.59 Chestnut Queensbury NY 12804
(Street) (City) (Stara) (ZJp Code)
who died on % day of F<rt'l w Y iy 20A
at C /e �vV l �lae.t f�Q41- Y uCe,tPA/►13bur+f NY
( ) (Address)
Name and address of nearest living relative or name of person aLetortarq cremation: I
Mrs �' Deter- va�i JO h A) l.}e-
(Name) (Address)
Reiatiorrsnip to the deceased 9+-5� 6 e- kek-)
Name ofFunerMHome Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)W%Wl pacemaker,�,battery,battery pads,power
veil,radioactive implant or radioective device in his or her body.(Gie)
I certify ova I have full power and audwrttation to arrange for the cremation of the ren aft and to direct the disposition of the
cremated remains,that any personal possessions have either beer,removed or may be destroyed,and agree to praect.defend and
Save hannlesa Pine View Crematorium firm any and all rani mis and demands for loss or doffuWs wlisf,may be made against them
by reason of or canntKad with the cremation of add remains as directed,whedw such,dab, ar demrartds are or ere not wholy
grotntdless,fate or fraudulent.
68 Main Street, Hudson Falls, NY
C � ( )
oad
nature mid Aadn
Relative or Legal Representative)
Signed on this date: 2 0 T
Disposkiion of Cremated Remains
I hereby direct Pine Vim Crematorium to dispose of the cremated remakts as follovvs:-
Mail to
Other arrangements-Please spadfy:
If p hver¢ation of Cremated remains is requested,dv*here XX
Revision:April 18,2007