Grow, Katherine rrn
PUYE VT QUEE9 "" � "`'-`
E'W CEMETERY AND CRE
QUAKF� ROAD, Q�ENSBURy, NEW YORKO 1R2 UM
(518) 745.4476 (518) 804
745.4.477
Funeral Director
-Name
Case#
Date Of Cremation
Time Cremation Started
`S -�u
r :me Cremation Completed
Type of Container
Remarks
iv O A h
qo.
Town of Qummsbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745- 477 '
AudwxtzaWn to Cremate
The undersigned requests and aut wrtzes Pine View Crarnalodum,in aowrdanoe with and subject to Ets Rulas and Regulations to
aemate the rams is of:
Katherine (Smith) Grow Female
(Name) (Sex)
ice) (CRY) (we) (Zip Cam)
vftdiedon the 8th day of September 20
at Cresent Manor Care Center Bennington VT
(Pima) ( )
Nears and address of rtaarest living relative or trams of pataort atttxwtc rtg awnstion:
Mr. Thomas Grow 37 Cedar Wood Dr.
(Name) (Address)
Fteletlonship to the deceased S o n
Narneat Funeral Rx. Carleton Funeral Home, Inc.
IMPORTANT- deftdie or,be". Y per,purer
bac
E rapraserA Bret tD the beet of ttty tatvndedge,the deo0asad no ,
call,rsddve Implant or=1108ctive device in his or her body.{
i cerely that I have full power and sulhorization to arrange for the crematica of do rename:and to dherX the dispoaitlan of the
cremated rarnairte,that any pammal posaaesiona have antler heart ratnoved or may be des h cq N ,and agree to protect.defend and
save hanrNeea Pine View CrameWitm from am and all clalnrs and demands riot bee ar damages w"maybe made agtMrtdt them
by reason of or con neciled wph the cr ntodm of add ttxnekrs as dk6d9d,whether suds Calms or darrtertds are or ere not%holy
groundless,tales or fraudulent.
68 Main Street, Hudson Falls, NY
(Address)
37 Cedar Wood Dr. Queensbury, NY
!/ (Sommurs and Address of Relative or Legal RepreeentatMe)
Signed on this date:
Disposition of Cremated Renteins
I hereby d nxl Pine View Crernaioriurn to dla4rose of the aemeted remains as follows:.
Mail to
Other arrange rnents-Please sp a cl N:
If puNwbation of cremated remains is requested,c wit hens XX
RevtsEart:April 18,2007