Mallon, Raymond rrO gtiN OF QUEEVBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Z,. I���`
Name �c,4Ap,,1 �.��� Tr , Case #
Date of Cremation Tull
Time Cremation Started 10 rlh
Time Cremation Completed fu1m
Type of Container �fc[L'Ifj o adf6fi O MCA5-
Remarks : r
Town of Queensbury
Pine View CerrIetery and Cremaltafium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Authofit to Cremate
The undersigned re gmft and autlhorixes Pkw View aarra odum,in accordance with end subject to its Rohs and Regulations to
crernate the tame is at
Raymond Mallon M
(Name) (Sex)
17 Ferry Street Hudson Falls NY 12839-
(su") (City) (state) (Wp Code)
rrfto died on day a 07/08/2009 20
at Glens Falls Hospital Glens Falls NY
(Pbm) ( )
Name and address of nearest Itvbp rek"or name of person au ffiod ng aerro ion:
Donette Ulrich , 4149 Rockwell Street, Hadley, NY 12835
(Name) (Address)
ROWWnsfttotft deceased Sister
NanteofFutenid1kx. Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knvwledg%the deceased(has)or(tree no)Pacemaker,defibnilator,battery,battery Pads,Per
aA,radioec&e kttptent or radioactive device In his or her body.(Ckde One)
1 0W*that I Neva fu0 power and augwdmdon to arrange for the c remedw of the remains and to direct the diapoaiticn of the
c rarraged remeins,that any personal poseessiom hews e10mr mean removed or may be destroyed,and agree to protect,defend and
save hanvftss Pine View AomaWrt jm from arty end dl dab nra and detnertds for bes or damages which may be made egrtirurt them
reemn a or cashecad wNh the crvnwbon of add reraelns as dkeced,whedtar such dab,hs a demertds are or are not wholly
false or 11raudWartt.
68 Main Street, Hudson Falls, NY
� �� -
(5ynature and A�reee of give or tegai Represerkative)
Signed on this date: ,� �'(✓�
Diepoeltion of Cremated Remeins
I hereby died Pkw View Crematorium to sepses of the cn mated remefrts as*A&&s:
Mail to
Other arnwVernerrts-Pieria WOW-
If pulveraedon of Cremated remains is requested,dreck here XX
Bevis=April 18,M