Mallory, Ann ?.CN.E ti'TEW CEM (ZU L LJ� Z 3 U
ROAp TERY AND CREMAT
' Q(lEeNS9URY, ORIUM
(S18) 745•4476 K�W YORK �28pq
(S18) 745•-4.477
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Town of Queensbury
Pine Yew Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Authorization to Cremate
The urK%wsigrW requests and sutNoribes Pine View CTemakwlum,in aecordence with and subject to its Rules and Reguiations to
csatvtate the remains of:
Ann Marie Mallory F
(Name) (Sex)
Lot 1, 1028 Dix Ave. , Hudsoin Falls, NY 12839
(Street) (City) (State) (zip Code)
who died on 2 2 nd day d May 20 0 9
at Glens Falls Hospital Glens Falls NY
(Place) (Address)
Name and address of ne®rest living relative or name of person autttoriang cremation:
Cindy Flanders 137 White Birch ESt. Ft. Edward, NY
(Name) (Address)
Rt kM0rWj,p t0 UV decaaeed Daughter
None of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to ffta best of my knowledge,the deceased(has) (has no) , :1004110110r,battery,battery peck.P0%'"
cell,radioactive implartt or radoecUm device in his or her body.(C
I certify that I have Tull power and audiorizntlon to arrarpe for tfta c wnsgon of the remains and to direct the disposaiun of the
cremated remairre,that any personal possessions have aitttar them removed or may be destroyed,and agree to protect.defend and
save tw mlass P"View Crematorium from any acid all chit and demands for loss or damages wfich may be made against#am
by feegm of' /rVV
or connac ted with dw cremation of add remains as dke0ed,whether such delms or darnards are or are not wholly
ar
68 Main Street, Hudson Falls, NY
l(Wiitness) (►°►ddrws)
��n137 White birch Estates, Ft. Edward, NY
L�
(Signature and Address of Relative or L Representedve)
Signed on this date: `S
Disposition of Crernatad Remains
I hereby direct Rine View Crematorium to dispose of the cremated remains as follows:.
Mail to
Other arrangements-Please spedry:
if pulver¢ation of cremated remz"is requested,dvx*here XX
Revision:April 18,2007