Prouty, Dorr w '
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E VIEW' CEMETERY AND CREMATORIUM
QUA-kER R0� DD, Q gNSB�y 04
NEW YORK 12804
(518) 745.4-476 (518) 745-4.477
Funeral ro Director
Namei2c r _Q� e
ot
Case# 51
Date Of Cremation
Tame Cremation Started
t6
Tame Cremation Completed
Type of Container _
off
Remarks 1G
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Town of Queensbury
Pine View Cemetery and Cremutofum
21 Quaker Road,QueensWry, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authorities Pk*View Crematorium,in accordance with each subject to Its Rules and Regulations to
cretrhate the terrains of:
Dorr Prouty M
(Name) (Sex)
Broadway Fort Edward NY 12828
(street) (cry) (Stara) (Zip Code)
Who died on 4th day of 11/02/2008 20_
et Glens Falls Hospital Glens Falls NY
(Plem) (Andress)
Name and address of ,im met lining five or name of person authortft cremation:
Dubes Rd. , Hudson Falls, NY
(Name) (Address)
Relatlorr Kp to the deceased Daughter
Name of Funeral lion re Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the beat of my larowiedge,the deceased(tree)or(tree no)paoemelw,deilbriNeW,battery,battery pads,power
call,radioecdve hnptant or nKkx cNve device In this or her body.(Ckde One)
1 Off*that I have fill power and suthorbatlon to arrange for the cremation of the remains and to direct the Clspoekion of the
cremated terrains,do any personal possessions have eMter t78en removed or may be destroyed,and agree to protect,defend and
save hartrtless Pine View Retnetorksre from airy and aN claims and demands for toes or damages which maybe made agoot them
by reason of or caxrecied wkh the cremation of add narrhalrm as dhected,whether such dabns or darrtartds are or are not wholly
�,f:r��ukhAertt.
(M 68 Main Street, Hudson Falls, NY
(Witness) _ ( )
Hudson Falls, NY
(Signatua end Address of Relative or Legal Representative) �—
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:.
Mail to
other arrangements-Please specify:
if pulverivOon of Cremated remains is requested,check here XX
Revisiam April 18,2W7