Peck, Kenneth rZ."O O
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E9RY AKD CREMATORiUM�
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�U�fCE3z ROAD, QV"-�1S91lRY,
(518) 745•4476 NEW YORK 12804
(518) 745'•4-477
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Town of Queetisbury
Pine View Cemetery and Crematotium
21 Quaker Road,Queentbury, New York, 12WX
Cemetery Ofkm: (518)7454476, Crematorium: (518)745-4477
Audlorization to Cremate
The u,dsralg,ed requests and auvxxtaes Pine View Ckemaarlum,In aoowdenmwkh and Subject to Its Rules and Regulations to
cremate the remains of:
Kenneth Hugh Peck M
(Name) (Sex)
69 Dublin Granville NY 12832-
(Stred) (City) (Slats) RIP Code)
sfio died on dayd 04/18/2009 20
Glens Falls Hospital Glens Falls NY
(Pbm) (ems)
Nsne and addrntss Of nearest IwbV rarws or name of parson suthoricng aenroslon:
Kenneth G. Peck 124 Chantilly Drive , Wcvnar
(Name) (Address)
40atlort"to the deCeSaW S on
NarnedFuroraltiorrne Carleton Funeral Home, Inc.
IMPORTANT:
i represent that to ft best of my ianowkKV%the deaeesed NO gor�Esno) Ielcer,deftdk Qar,belt y,baWy pack,pmmw
cK radioactive biq ttt or radioactive device in his ar her body.(
I our Wy that I trove tt/power and suftdcatlon to arrange for the asmeft d the rernakis and to dkerd the disposition of the
cremrsted rarrnah ,that any perepno poseessior»have elver been removed or rosy be desb yed,and agree to protect,defend and
save hamrdeas Pbw View Cranoftritim iom ttry and 81 tdai HOW denser"1 for kres OF detttapes wNdh may bs n+ade agtrinst them
by reason d or cannecied wNh the crsnradw of said tettralrts as drecled,vdmdwm such claims ar demands are or are not wholly
false or
fi /" 68 Main Street, Hudson Falls, NY
124 Chantilly
(SigneWre and of#rive or Lsgal Representetive)
T
Signed on this dete:
Dispoeftion of 0ameted Remains
I hereby direct Pine View Crernalorluml to dtapcae of the aerrroted remains as%40ws-
Map to
Other anangenwo-Pieeae spm*f.
If puhwbaticn of Cremated remains is requested,dw&here XX
Rem April 18,2007