Nicklos, Michael f ,r .�•
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-T QUEE9\�5rBU
PLNE W CEMETERY AN
QU&Y—'z—R ROAD, QU'8r CREMATORIUM
URY, NEW
PORK 12804
(518) 745.4476 (S18) 745.•4-477
1✓1. Funeral Director t
-Name l 1 Ilc1 �'i ��cCased 11S
Oa � e Of Cremation
Time Cremation
Started 700q
T : me Cremation Completed to.
Ty ?e of Container
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Remarks
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Town of Queensbury
Pine View Cemetery and Crematotium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium. (518)745-4477
Authorization to Cremate
The undersigned regumb and audxxt es Pine View Crematarlum,In accordance with W4 subject to its Rules and Regubtiorrs to
cremate the remains of:
Michael Paul Nicklos r/VIu�L
(Name) (Sex)
6.7 Maple Street Hudson Falls NY 12839-
(street) (cry) (Slum) (ZJp Code)
who died on 4th day of October 2008
at Glens Falls Hospital Glens Falls NY
(Piece) (Address)
Name and address of on no Imng retetiva or name of person authorizing a wnstitm:
Teri Nicklos 67 Maple St, Hudson Falls, NY
(Name) (Address)
Reledonship to OW daCeared W i f e
Nanreof Funeral tion Carleton Funeral Home, Inc.
IMPORTANT:
I mpaservt that to the belt of my knowledge,the deceased(kiss)or(hen no)pacemaker,dailbdietor,battery,battery per,pore
ca,radloactive implant or radbw ve device in trio or her body.(Ckcie One)
i cev*that I have AA power end audwrizetlon to arrange for the cremation of the ramalns and to dlrorx the disposition of the
cremated remains,that any peraoned possessions have either been removed or may be desboyed,and agree to protect defend and
save ham*"Pbo View Crematalum from wry end aN claimant demands for foes or dernagss which maybe made against them
by reason of or caxtected with the cremation of said n naakts as directed,wh6dW such daittta or dertieni de are or are not wholy
� false or
/� ✓� 68 Main Street, Hudson Falls, NY
(►+ ) (Address)
67 Maple St. , Hudson Falls, NY
(signsium and Address of Relative or t egai ROVOS AS Me)
Oct. 4, 2008
Signed on this date:
Dispoekion of Cremated Remains
I hereby dlred Ping View Cremauwkn to dispose of the cremated remebw as Wows:.
Mail to
Other arrangernerm-Planes specify:
if pulverization of Cremated remains is mWesied,check here XX
Revision:April 19,2007