Gibson, Lorraine ' r
i
rT n W71 C OF QUEEN4,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name �.bc�a�ne C 1 �sc,r Case # M
Date of Cremation
Time Cremation Started Q%00 A M
Time Cremation Completed I� ,��� /l�7
Type of Container 6,rlotj �ovr FT 12sr C85►=
Remarks :
�j �; �� M��� T''I� �1m
to ;i�� �
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Town of Queensbury
Pine View Cemetery and Cremaknium
21 Quaker Road,Queensbury, New York, 12844
Cemetery Offlc.e: (518)745-4476, Crematorium: (518)745-4477 '
AudwxUalon to Cremate
The undersigned requests and sulhorbw Pine View Cremawdum,in aocordence with and subject to Its Rubs and Regulations to
aarriete the remains of:
Lorraine Gibson F
(Name) (Sex)
38447 Stafford Drive, Zephyrhill, FL
(Street) (City) (State) (ZIP Code)
wlto died on day of 0 7/13/2 0 0 9 20_
at 28 Applehouse Lane Queensbury NY
(Place) (Address)
Name and address of rtliareet living r+etat M or name of person au ttorWM arernatbn:
Mary Gibson 2171 India St. , # F, San Diego, CA
(Name) (Address)
RekMorvoV to ft deCeeaed Daughter
Namect Funeral tkx. Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the beet of my latowledg%the deceased(hew)or Bno centdcer,dWxNeW,battery,batlery peck,power
cep,radio ecdve Implant or nKkwx w device In his or her body.( )
I owft that I have fug power and nuft izatlon to arrange for the cn ntadon of the rernaft and to dtreot the depoellon of the
cremated rameirts,that any personal poseeaskmw have airher been removed or may he deedreyed,and agree to protect,defend and
save hernvm Pine View CropefOriu+e from whir and all claims and demwhds for loss or damages which may be made agoindt them
by reason of or corrected wlsh ft asaredon of add rotrtelns as dAwleck whadw such dsirtes or damends sm or are not wh*
groundlows,false or*audulent.
68 Main Street, Hudson Falls, NY
(Address)
and Address of Relative or Legal RepresenWive)
Signed on this date: July 13, 2009
disposkion of Cremated Remain
I hereby Bred Pine View Creatatorkmt tO diapers of the cremated remains as Wows-
Mail to
Outer arrangements-Please sp KW
If pulverization of cremated refrains is mWeeled,dteck here XX
Revk oan:April 18,2W7