Willson, Ethel ri •
rrn
OF
.QUEE9�50uPPINEV1EWCEM 1 �.J
QUAKER ROAD ETERY AND CREMATORIUM
' QUEENSBURY, NEW YORK 17804
(518) 745.4476 (518) 745.4.477
r II i Funeral Director
e F+6 �A' r "--
,�'am 6.
•V i ISU-
Case#.
Oa+te Of Cremation S 7
lime � 1 CX1
Cremation Started
I :/v
T ; me Cremation Completed gJca
Q
Type of Container
A rf fC(l kv/TTT
Remarks 2�/�
MA'rN i ,2U M
2: 'oP
Tom of Queerrsbufy
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Qliice: (518)745-4476, Crematorium: (518)745-4477 '
Authorization to Cremate
The undersigned requests and audxxtaw Pine View Crematorium,In eomdence vdh and&Mod to Its Rules and Regubtkxw to
cremate the remains at
Ethel M. (Murray) Willson F
(Name) {Seek)
Adirondack Tri-Co Health Care Fac Johnsburg
(Street) {City] (Starts) (Zip Code)
►vho died on day of 09/12/2008 20_
at Adirondack Tri County HCF Johnsburg NY
(Plane) (Address)
Name and address d naoreet iivMg mtativa or name of Pam n authorb*v caernaflort:
Jane Alexy 37 Overlook Drive
(Name) (Address)
Relation"to the daoaaeed Cousin
Nam d Funeral Harna Carleton Funeral Home, Inc.
IMPORTANT: ,
1 represent that to the best of my iahvwledge,the deoessed(has) {has pamnaker,ddlixiAaRor,battery, y Pam,pea'
cell,radioactive imptenl or radioactive device at his or her body.( )
1 ow*that I have U power and eWwrtzetlon to arrange for the cremation of Use renmirm end to As the disposition of the
cremated reinsure,that any personal poeseesbtte have ell ar been rerrhoved or may be destroyed,and agree to protect,defend and
sous hormim Pine View CrecaebAm from arty and all cfaiFns and demands for ion or damages which may be wtede against them
by reason of�caxtecied wNh the cremation of sold remmins es directed.whahar such dab, ar demands are or are not wholly
qWndbW
68 Main Street, Hudson Falls, NY
cv+ ) ( )
37 Overlook Drive, Queensbury, NY
-� (.rignatue and Relative or Legal Represerrteihre)
Signed on this date: SP n L f -A O G
Dispo k on of Cremated Remeft
I hereby direct mine View Crematorl m to dtapoae of the cremated remein s as fdlohrrs:.
Mail to
Other arrangemem-Please spedfy:
If p*mdzation of awnated remains is requested,check here XX
Revision:April 18,2007