Kuriplach, Ella �O OF QUEErV5(BUjK,
PINE VIEW CEMETERY AND CREMATORIUM
gVAKER ROAD, QUEENSBURY, NEB, PORK 12804
(518) 745-4476 (518) 745.-4-4.77
7
Funeral Director
Name
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BC
••on Case#
Date Of Cremati VI
- 004f.n,L r
Time Cremation Started "7;?6
Time Cremation Completed
Type of Container
`"c OctI ow f
Remarks
7`',&u A
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# 510
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)7454476, Crematorium: (518)745-4477
Auttwrizadw to Cremate
The unden0grted requests and adhorines Plea View Crematorium,In a=dww with and s#vl to ks Rubs and Ragtrbtkxts to
ownete the remetins at
Ella Kuriplach Female
(Name) (Sex)
1.6 Franklin St. Glens Falls NY 12801-
(Sb1w) (C" (Stets) (7J p Code)
rdto died on 4th day of November 2008
at Glens Falls Hospital Glens Falls NY
( ) ( )
Name and address d nearest living relewflMe or name of peraae atttttorb!kv cnwn *n:
Ella Kuriplach 16 Franklin St.
(Name) (Address)
RNatior4M to the deoSseed Fa t he r
NamedFunecalHome Carleton Funeral Home, Inc.
IMPORTANT;
I represent that to the bast of my krwwkx*,dw deceesed(tws)CWO"i*Mwwndw,deftNator,bWary,beaery Peck,power
C",rodioectivve implafd or nNSD CtWe device In his or twr body.(Clyde One)
I cw*thet I twee Till power and eugwrb ntlon to anwW Tor the 0VnWdW of the ren akts and to direct the diepoakian of the
crenated ranoko,60 any peneorrel poeaaeskno have eiffwr baen removed or may be desbvied,and agree to protect,defend and
save hany"m Pine View CremeWFIm Trom wy and al dairrrs and demands U bee ar dwopes whkh may be made egal R them
by reawn d or conneaed wkh tin cnwm m of said remakes es diecied,whether such daki or demands are or eta riot wholly
groundba,false or*anduiert. .
i 68 Main Street, Hudson Falls, NY
(Address)
16 Franklin St. , Glens Falls, NY
(?newle and Address of ReWWe or LwW Representative)
Signed on this date:
Dieposkknt of Owneted Remelts
I hereby direct Pine VW w Crematorkim to dispose of the cremated remains as*Mows-
Mail to
Other arrwVwnwm-Please specify:
if pthwketion of cremated remains is requested,Check here XX
Revision;April 18,2007