LaRoe, David rZ."O O
-7 QU rZ E
P.CN E YT E W 23 U-` `J
�U.�3C�R RO/C M�TERY MrO CREMATORIUM
QUEe.NS9URY, NEW YORK 12804
(518) 745.4476 (518) 745.•4-477
Funeral Director C 1 t �O—
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Town of QueensWry
P(ne View Cem lery and Crematorium
21 Quaker Road,QueensWry, New York, 12804
Cenwtery office: (518)745-4476, Crematorium: (518)745-4477
Auft izadon to Cremate
The undws%,nWraquesftand au #tares Pkte View Cremewdum,in accordance wfth end aubjed to Its Rules and Regulations to
creeme the ramekra of: M
David Kenneth LaRoe
(Norm) (Sect)
1.19 Wilton Road Northumberland NY 12831
(Shl") 0*0 (State) (71p Code)
who died On 2 5 t h dayofApril 2009
—
2370 Route 46 Fort Edward NY
at (>'ISM) (Address}
Name and address of newaet Ili n**"or name of person w9wr"V cremation:
Wendy LaRoe Route 46, Fort Edward, NY 12828
(Name) ( )
Daughter
RetationS W tp the deceased
Carleton Funeral Home, Inc.
Name d Funeral Home
IMPORTANT:
I rs reedioe implant d of ,� h body.00or#10 One)pacemaker,�,beKiary,beaery ,Pawer
t oar*Brat i have fill power and wA haf¢atlon 1D arrange for the crerr dkO of the ramak a and to direct the di to pntl s orb and
have 9Wjar bean rwrwved or may be de troyed,and spree Pam•
aarthatsd rerrheirhs,that any pereorral P yny and eN debm aid demands for foss or damages whieft may be made agakrrt etrem
save harmless Pk*View CrentetorWne d said remakts as dk�eded,whedw mich dd=or demands are or are not hMwlly
by F0300n d a Win-dtad wit ttre
false kx
68 Main Street, Hudson Falls, NY
W1.
(Address)
2370 Rte 46, Fort Edward, NY
( and of Fiou"M or Legal Repre.ernatNa)
Sgnad on this date.
Diepwkion of Cremated Remeins
I hereby dkec t pine Vbw Crematorkxn to diaPaee Of the cms►ated remakhs as"o .
Mail to
Other arrangements-Please specify:
tf pulverization of Cremated remains is mqussted,check here XX
Revision;April 18,2007