Goodsell, Heidi TC O
Pwg YTEW CEM QU N ���`� B Ll
U R ROAD, �TERY AND CREMATOR[U
Q11E1?NSp URY, M
(518) 745.4476 (sl 1YEw YORK 12804
s> 745••4"477
Funeral Dire 1 '
Director 4+rIL�G
C8Se /
Crematf.on
Te cremation Statj
rte
T.e : remaclon Completed
�oncalne
ru/u
Town of Queensbury
Pine View Cemetery and Crematodum
21 Quaker Road,Queensbury, New York, 12844
Cemetery Office: (518)7454476, Crematorium: (518)745,4477 '
A lthodzetimt to Cremate
The undersigned requests and au#xxl es Plne View C:rernatarlurn,In accordance vft wod subject to Its Rules and Regulations to
aertrate the remains d:
Heidi Ann Goodsell F
(Name) {Seat)
1.028 Dix Kingsbury NY 12839-
(Sh") (CRY) (Stara) (ZJp Code)
YAw died on daYof 03/22/2009 20_
at Residence Kingsbury NY
(Place) O
Name and address d nlsaresi Itvirrg relst W or mama of peraar►aclittor zhV Cnm mftm
^Dale Goodsell 1028 Dix Ave, Lot 38 L �-�,� '4s" T71-11�
(Name) (Address)
Reletioreft to tl18 deGea98d Husband
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the beet of my knowledge,the deaessed(has)or(tree no)pacemaker,dedbrilalm,beft y,battery peck,power'
OK radloective irnptant or mfloective device In his or her body.(C kde one)
I earthy Chart I#rave full power and nuftwtmdon to arrange for the cternadon of the renmbr s end to dVW the depoei<ian of the
cremated remain,that any personal 911 q 14siorte have ektmr heart removed or may be deft oyed,and agree to piotect.dererd and
save henttlees Plate View Cnttttetodw from any srd all claims and datnerds fa loss ar dsntttgss wfttch may be n"ds agdnst them
by reason of or cantec led wkh the cremation of said remelts as d eMd,whether such dO, ar kierrrarx a are or ave not wholly
false or
68 Main Street, Hudson Falls, NY
( )
1028 Dix Ave,
(Signatcne and Address of or Legal RepreserrtatIve)
signed an this date: -M ecA �Z it ��9
Disposkion of Cremated Reme'irte
I hweby direct PMe view Crematorkwn to dispose of the o w tad remains as follows:.
Mail to
other amingerneras-Please specfy-
If pulverbstion of cremated rernsins is requested,check here XX
Revision:April 18,2W7