Middleton, Lawrence pro RAN OF QUEEN, B URY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Namew�hc,I I Il CIGC�G�. Case #
Date of Cremation FuLq 31 ZUoq
Time Cremation Star --ed A.f1
Time Cremat -'.on Comp 3ted
Type of Cor ---ainer inc� Ohi
-T P5 i
Remarks :
3 3.3
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476, Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
Lawrence Middleton Male
(Name) (Sex)
51 Old Mill Lane Queensbury, NY 12804
(Street) (City) (State) (Zip Code)
who died on 3 0 t h day of July 2k0 9
at His Home
(Place) (Address)
_!!p�and adqm of newest lative or name of person authorizing cremation:
51 Old Mill Lane, Queensbury, NY 12804
(Name) (Address)
Relationship to the deceased W i f e
Name of Funeral Home M.B. KI lmer Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has )pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made agaurst them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
gro less,fah udt l,L
(Witness) (Address)
(Signature and ress of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006