DeWitt, Norma Q
P�E .YTEPY CEM "���J��B
4 ROAD TERY ANo CREMATORIUM
(Sl$) 74QV .SBVRY, KEW
YO 128pq
(318) 745'•4477
Funeral Director
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Town of Queertdury
Pine View Cer Wary and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Authorization to Cremate
The undersigned rile and mdwrtaes Pkre View Cramakwlu t,In sawdw"with"AMed to Its Rules and Regulations to
aenwe the remains of:
F
Norma Ruth (Haas) DeWitt
(Name) (SWO
Fort Hudson HCF Fort Edward NY 12828-
(S"M) (City) April (Sws) (�p Code)
llth
who died on
day� 20
at FORT HUDSON HEALTH CARE FAC. Fort Edward N
( ) (Address)
Name and address of ionrest living nArJm or trams of posm aLoWdanD aemadon:
Robert J. Bergman 17 Oak St. Fort Edward, NY
(►me) (Address)
Son
Raiationellip to the deCessed
Named Funeral l-lor, Carleton Funeral Home, Inc.
IMPORTANT:
I Mveeent mat to the bed of my lawwiedge,the deceased(has)or(has no)paoenn®kw,ddbrulator,beery,bWery per,power
Cell.radkwcbve impiant or radioeclive device In his or har body.(Cirde One)
1 Certify Out I#rave full power and authorization to ananrge for the Cramsli 0 of the rerrreft and to direct the disposition of the
cmmnatod remains,that WV Personal Pests have edlnar been removed or May be desheyed,and agree to protect,defend and
gave hw t "Pk*View CrW*Wrkart from any 8nd ON tiaittts and dantands 1W foes or dannsges tMtieh may be made apold#hem
by reason Of Or CMWMC ed ft cnmmtion of said nettnefrts as dAuNd,vrlWW sudt dabs ar demands aria or are not wholly
i , false or in Street, Hudson Falls, NY
d'711Oak St., Fort Edward, NY 12828
(Signaturij1end Address of Reletive or Legal Represental e)
{
Signed on this date: L
Disposition of Cremated Rernshe
I hereby dbed Pine View Crwndorkan to dispose of the cremated reruns es fouows:.
Mau to
Otter arrangernervis-Planes specify:
XX
If pulvedzetion of Cremated remains is requested,diedc here
Revision:April 18,2007