Powhida, Martin �o OF QUEE9\�5OUrPW STEW CEMEE �J
CEMETERY AND CREMATORIUM
QUAKER ROAD, QijgFNggUy fix, yORK 12844
(518) 745-4476 (518) 745'-4-477
l ff Funeral Director
Fame— �f'Ct.. �uw1.•�S
Dace Of Cremation
01
T !me Cremation Started
Time Cremation Completed (o ;p(7
Type of Container
'Pvc�r T 6A ..
Remarks
A Al
I
�oo� � u • yoAn
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Town of Chmw*bury
Pine View Cemetery and Cr+emakmium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745- 477
Authorization to Cremate
The undersigned requests and&**rims Pk*View Cmmdadum,In a000rdetwe wkh and su*d to ks Ruin and Regubtbna to
cremate the remains at:
Martin Michael Powhida M
(Name) (SOX)
5.07 Lower Wright eE�dward NY 12828-
(SUBM) (CRY) (SUM) (ZJp Code)
whodedon the 26th day of February 2008
at 507 Lower Wright Street Fort Edward NY
(PISM) (Addrew)
Name and adddrress of rtefreat Ikktg MINd re Or name of peraont autttort&V aerrration:
Mrs. Jean Powhida 507 Lower Wright Street
(Name) (Address)
Reiudans tq7 to the deceased Wi f e
Norm dFuneralHome Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the beat of my Iarowledge,the deceased(has)oeteceffm 'defib NOW,batten►,belfry per,Pmm'
C",radkwctive implant or radkxm* a davioe In his or her body.{
I ON*that I hum full power and eudwdndon to arrange for the cremokn of the remakre and to d1i the dispoegion of the
cremated rerrrakrs,that arty personas poesessions he"eNhar bean removed or may be desbayfd,and agree to proied,defend and
am ham*"Pine View Cr4meWd=from any end al cini -s and dex ovis for lams or dernages which may be made apeirtet Stem
by reason of or canneciied wNh the aenwdm of add nw akis es dki0ed,wheieher suds tidins a derriartds are or ere riot*Kft
grourtdltsss,+else adders•
68 Main Street, Hudson Falls, NY
(YIIRrtess) (Address)
7 Lowe Wri ht Street, Hudson Falls, NY 12828
7S
(Signature e6d Address of ROW" fgai Repreeerttettve)
Signed on this date:
Disposkion of Cmmetad Remekte
1 hereby dyed Pine View Crernetorium to dlap0e8 d thf awnOW remekts M id10"'
Mail ID
Other omngwnertts-Please sped/y
If pciw zedon of emmeftd remains is req mstfd,deck bane XX
RevisIon..April 18,2007