French, Milton `1`0 74N OF QUEEN,5BU-9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �"ItA(l,
Name M-1 �TO' ff"erA Case # 3LQ
Date of Cremation u�Ust �� . 2oO
Time Cremation Started
Time Cremation Completed
Type of Container CASE
Remarks :
MAIN Moues glo Ah
`06 � �7
17' Sd
I
I
I
I
I
i
I
I
Town of Queensberry
Pine View Cemetery and Crematafum
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Cremeto ium: (518)745-4477 '
Authorization to Cremate
The tmderslgned requests and a omriaes Pk*View Crematorium,to amordanoe with arxf subjed to ks Rues and Regulations to
cromete the remains of:
Milton E. French M
(Name) (Sex)
Indian River NH &GrRah,cablle NY 12832-
(sh'eet) (CRY) (SWe) (ZJp Code)
who died on 14th day of August 2009
at INDIAN RIVER REHAB & HLTH CERI�nville NY
(fie) (Address)
Name and address of noereet living rakdw or mama of person audxwb ft c n nrabm
Sharon Pollack 11 Seaford Pl, Boynton Beach, FL
(Name) (Address)
RekM rt9hip to the deCea9ed Daughter
Nante of Furaral Home Carleton Funeral Home, Inc.
IMPORTANT:
l represent that to the bast of my tarvwkKV%the deoeese+d(has) (has no) nteiccr,deft9dtor,battery,betWy per,power
oel,radloacdve knptant or radoac ove device in his or her body.(
I oerdy that I have frill power and acrdwrization to arr engo for fha crenu dW of the remains and to direct the disposition of the
cremated rem**,that arty personal poeseaskWo have ONO been ramroved or may be destroyed,and agree to piotect.defend and
seve honrdeas Ph*View CrsmeWrksrt from ww and al dale and demoub for bw or damages which may be made egallnet them
by reason of or eorstec wd wkh tM txe w*m of said remelts as directed,whether east deirtts ar den'srrds are or ere not wholy
false or fiaudulent.
M 68 Main Street, Hudson Falls, NY
F
(Synsixe and Adcke��sa of Relative or#regal Representative)
ign /
S ed on this date: /' '`may
Disposkion of Cremated Remeine
I hereby sired Pine View Crematorium to dispose of the cxemeted remalris as follows:.
Mail to
Other arrangernents-Please specify-
If pAverWMon of cremated remains is cegxsted,duck here XX
Revision:Apri118,20M