Belair, Emma OF
QUEE9\�souT"y
PINE VIEW CEMETERY AND CREMATORIUM
QVAkER R0AD, QUEENSBVRY NEW YORK 12804
(518) 745.4476 (518) 745-4.4.77
Funeral Director rr
•- , ,�.
,,\'ame tm401&�
`'' Case#
Date Of Cremation QC �cr
Time Cremation Started
Z*.$0 Pn
Time Cremation Completed
Type of Container
ITN C k-
Remarks
2; kv
i�So
F
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477 '
Authorization to Cremate
The undwsignsed requests and"Mrtz es Pkte View Crernatarlum,in aacadmm wkh and subject to Its Rules and Regulatbns to
c mvwe the rernelre of:
Emma C. (Carpenter) Belair F
(Name) (SOX)
Fort Hudson HCF Fort Edward NY 12828-
(Stnset) (CRY) (Swe) (ZJP Cam)
23RD day October 2008
v*o died onat FORT HUDSON HEALTH CARE FACFort Edward NY
(Place) (Address)
Name and eddre8s of naaraet IivbV releeivve 0r name of perffion audXWl2 kp Cremation:
Jackie Snowden 104 Allen Road
(Name) (Address)
Reiatlonship to the deceased Daughter
Name of Funeral lim. Carleton Funeral Home, Inc.
IMPORTANT:
I represent that d the beet of my knowledge,the deceased(hw)or(Yens Oacemelw,deBbriAet r,battery,boary Peck,Power
090,radloective kt ant or radioactive device in hie or her body.(Ckde One)
I ow*that 1#revs U power and eutlxwIzn ton to arrarpe for the aemegon of the rema ne and to dkea the dispoeftm of the
caanm*W serf#,that any pereonW poseeesbris have eM m been removed or may be deftroyed,and agree to profecL defend and
save hanwees Plne View Crsmetorium from any and al dab and demands fror bes or demapss wftich may be made ago"a them
by meson of or omnecsed wkh tM cremation of said terrrekte se dkesied,whedrer such dakrt8 or dernerr isms or are not wholly
groundless,false fri udslertt.
� 68 Main Street, Hudson Falls, NY
(Wines) (Address)
1 4 Allen Road„ Glen Burnie, Maryland
and Address of Relative or Legal Represergadve)
Signed on this date.
Dispo ltion of Cremated Remekts
I hereby dared Pine View CremaWlum to dispose of the aemsted remelhs as Wows-
Mei1 to
Other armVerna is-Please spedfy:
If pAveraation of Cremated remains is mWested,dmrk here XX
Revfslon:AprN 18,2007