Carlisle, Jean OF QUEE-�� 523Ur
PIN
E VIEW CEMETERY AND C
QUtiKF�t ROAD REMATORIUM
QUEENSSURy, NEW YORK 12804
(518) 745.4476 (518) 745-4477
_ Funeral Director L
Name
C a s e#
Date Of Cremation
4s j3 2�b�
Time Cremation Started
7% v (�
T ;me Cremation Completed Z(�
Type of Container
oar•,- S I
Remarks
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Tom of Queensbury
Pine View CemebM and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477 '
Authorization to Cremate
The uidwWgned roam is and authorizes Pine View Crematorium,In eacardence with and sabjed to its Rules and Regulations to
cremate the remains d:
Jean Williams Carlisle F
(Nome) (S")
327 Broadway Fort Edward NY 12828-
(Sirem) (CRY) (Scala) (OP Code)
vvho died on 8 t h day d August 2()0 8
at 56 Bay Road Lake Luzerne NY
( ) ( )
Name and address of nearest Bring rsieitive or named person aumorb*V avnmoon:
P-tt„" A �'/u f� L3 (k,k 14) Ca,,
(Name) (Address
Relationship to the deceased Lv l Y h
Name of Funeral tkno Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge,the dweea d(has) #m ndLpdcemslw,der willietor,batery,battery peck,power
call,radioactive implant or radioactive deride In his or her body.( )
I denary Bret I here full power and audwrb scion to arrange for the cremeftn of the remains and to direct the disposition of the
cremated remains,that any personal possessions have eM ar been rarnoved or may be destroyed,and agree to protect,defend and
save twanniesa Pine View Crameloritm from wW and all claims and demands for roes or damages which maybe made against fhem
by rewoolfor carrtecied wqh On cremation of said netrrairts as diiecded,whether such rim'rtts ar dartrartds are or ere not wholly
grori
false or
68 Main Street, Hudson Falls, NY
( ) (Address)
(Signab"end Address of Relative or Legal Represertative)
Signed on this date: Y�q
/0 ---- -
Disposition of Cremated Remains
I hereby direcd Pine View Crematorium to dispose of the cremated remains as fddwer.
Mail to
Other arrangements-Please specify:
If pAverastion of cremated remains is reqnsted,check here XX
iRevWw..April 18,2007