Jackson, Francis rZ_O O • •
?w� YlEW CEM QU
C�I� R ROAD, TERY AND CREMATORIUM� \J
Ql1E>a?y59URY, 128p4
(518) 745.4476 (Sl8) 74 NEWS' YORK
.4477
—� Funeral Dic
retor
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�d e �� Crema Casey 153
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^e ' ' emation Started
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: remation Completed 70
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Town of Queensbury
Pine View Cem W"and Crerrokmium
21 Quaker Road,Qtmensbury, New York, 12804
Cemetery Oflice: (518)745-4476, Crematorium: (518)745-4477 '
Auttwrization to Cremate
The unhdersigncad mWesb and eulhortaes Pine View Gnematarlum,In amordenoe with and*Mod to Its Rubs and Regumbne to
cremate the remeine of:
Francis Edward Jackson M
(Name) (Sex)
1.8 North Rd, Moreau NY 12803
(SU") (Clty) (State) (Zip Code)
who died on dayd 04/20/2009 20_
The Orchard Health & ae,k". Granville NY
( ) ( )
Name Ord of , to Iivbrg rehWoe or name of perean+tuhlthorbft aemeMon:
Mrs. Anna Maranville /45 Elmhurst
(Nance) (Address)
R01000rIft 10 nhe deceased Daughter
Name d Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
i repr+eserct the tD cite beat d my tawwledge,the deoeesed(firs) (hea no ,deebdlator,battery.battery pads,power
CX^radioactive irrcptarx Or radioecsive device In this or her body.
I ow*that I hwm fill power and nuftntmdon to arrange for the cremske of the nKru*a and to direct the 6spoeitlon of the
cremated remains,that my personal poeeesslons have aM m been removed or may be destroyed,and agree to piotect.defend and
hemass Pine View Cremelmiu rt from any and al dairtts and demands for bee or demages which may be made ego 1 41 diem
by d or connected wkh tin c smation of said tetrhdrts as drecled,whedw such cairns or den'a ds are or are not wholy
68 Main Street, Hudson Falls, NY
(Wir'less) ( )
1[ 145 Elmhurst
(/� (Signatuo�Ad&LofRefs n or LWM Represents") t a F o H
Signed on this date:
Dbposbon of Cremated Reme4"
I Nmeby Bred Pk*Vkw Crernetorkhm to dispose of the cremated remanns as follows:
Mail to
Oacer arrange -Pkeae WW*r_
If pulvefe ion of cremftd remains is reWested,d*&here XX
ftevwm April 18,2007