LaClair, Vera L O OF QUEE
P W E V(E'4Y CEMETERY r� '" O U 1��..J
AND CREMATORIUM qU9tKER ROAD, QUEE.NSBURY NEW YORK 12804
(518) 745.4476 (518) 745*•4477
Funeral Director
dame
� r Case#. ) 5 �I
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container
�Ntr 1 1- E
Remarks
4V
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 undersigned requests and authorizes Pkhe View Crematorium,In aocardanee with and subject to its Rules and Regulations to
cremate the remain ot:
Vera M. (LaFarr) LaClair F
(Name) (Sex)
5. Michael Road Fort Edward NY 12828-
(ulse) (City) (State) (ZJp Code)
who died on 1 s t day of Ice c e(mb e r 2008
at Glens Falls, NY
(Place) (Address)
Name and address of nearest living reladva or name of person authorbiV cremation:
Mr. Gerald V. LaClair 5 Michael Road
(Name) (Address)
Rekff0rW*to the deceased Wife
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knorrit+dge,the deceased(has)or(has no)pacemaker,def n ISW,battery,battery Pack,power
ca,radk ective implant or redroec Live device in this or her body.(Circle One)
1 oertify Gut I have U1 pawer and audwrizatlon tp arrange for the cremaak n of the remains and to direct the dispoeblon of the
cremated remains,that any personal possessions have eidtar been removed or may be destroyed,and agree to protect,defend and
gave hamnlm Pine View Crertr8kxIum from any and all dab. and demands for toes or damages vAdd may be made against them
by reason of or connected vrilh the cremation of said remains as direr,'ted,whether such claims or demands are or are not w"
grourd ,false or Ilaudulertt.
68 Main Street, Hudson Falls, NY
L ` 5 Michael Road
(Signature and Address of Relative or legal Representative)
Signed on this date:
Disposition of cremated Remains
I hereby direct Pine View Cremakwlum to dispose of 0*cremated remains as Follows:.
Mail to
Other arrangements-Please spedry:
if pulvwizetion of Cremated remains is requested,c�hedc here XX
Revtsian:April 18,2007