Swinton, Richard L O qx� OF QUEE9Q(3U2rAND CRE
D ER ROAD, Q J,ISBURY MATORIUM
NEW YORK 128o4
(518) 745.4.476 (518) 745'-4.477
Funeral Director
Ca s e; .
Oate Of Cremation Cv
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Time Cremation Started
Time Cremation comp
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Town of Queensbury
Pine View Cetr lwy and Crematoium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476,Crematorium: (518)745-4477 '
Authorization to Cremate
The urxisrslgned requests and andhorixes Pk*View Crematodum,in aacorderroe with and subject to its Rules and Regubtiom to
cremate the rernskts of:
Richard LeRoy Swinton M
(N13n1e) (Sued()
1.6 Roger St. Fort Edward NY 12828-
(strhhet) (city) (slats) (gyp code)
who died on 28th dayd December �08
at 16 Roger St. Fort Edward NY
(Place) (Address)
Name and address of op no Itvkrg nhl Wft Or name of person au010rt2ng cremation:
Donna Swinton 16 Roger St. , Fort Edward, NY
(Name) (Address)
Wife
Reietio-MV to the deceased
Name of kworal lkx. Carleton Funeral Home, Inc.
IMPORTANT:
I represent two to the bed of my knowledge,the deoeasad(has)or(has no)Pacemaker,daiibrilla tor,be",betWy pack,pa'
cell,radioactive irrrpiern or radioactive device in his or her body.(Ckde One)
I certify tire[I have fue power and authorization to arrange for the cremeHon of the remains and to dkect the disposition of the
c ranv"d rarrwrkrs,that any personal possessions have anther theerh removed or may be destroyed,and agree to prolect,defend and
save harmless Pine View CreMsiarkan from any and al claims and demands for ices or damages which may be made against dram
by a canrtecbd 1M cremation of said nemektB as direcied,whether such dakrts or demands acre or erw not wholly
fdsa or
68 Main Street, Hudson Falls, NY
(WInew) (Address)
pL�M✓� Roger St. , Fort.Edward, NY
FJ� 7 (.�,ignaturp�J and Address ReiatiMB or L%O Represenietive)
signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View CramalOrllhrn to depose of the cremated remains as Hollows-
Mail to
Other errmVernenla-Please apedfy:
If pulverization of cremated remains is requested,cam&here XX
RsvWkvL April 18,2007