Willett, Charles 1
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rO T�N OF QUEEVB 2 92 Y
PINE VIEW CEMETERYAND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Funeral Director
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Name_ Ac-L3 Case #
Date of Cremation ��,o5t (Z t zu)q
Time Cremation Started
Time Cremation Completed Type of Container L�- aOk CQ�wC09D FIR 5T CASE
Remarks ;
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lo:O 99 I
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Town of Queensbuiry
Pine Yew 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 authorises Pine View Crematorium In eocordence with end subject to its Rules and Regulations to
cremate the remains of:
Charles Mark Willett M
(Name) (Sex)
4.9 Putnam Ave. Fort Edward NY 12828-
(Street) (City) (State) (Zip Code)
who died on 8 t h daYof August 2009
at 49 Putnam Ave. Fort Edward NY
(Place) (Address)
Name and address of nearest living r etativa or name of person aulhormrg cremation:
Nancy Mickel 49 Putnam Ave. - Fort Edward, NY
(Name) (Address)
RelationOV to the deceased Partner
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the befit of my kmNAedge,the deceased(has)or(has no)pacemaker,def brVator,battery,bathxy per,power
cell,nKNoective implant or rafioactive device in his or her body.(Cirde One)
I certify that I have full power and euthorbmdDn to arrange for the cremation of the remains and to direct the disposdion of the
cremated remains,that any personal possessions he"either been removed or may be destroyed,and agree to protect,defend and
gave harmless Pbv View inn firm any and all ciaiFrts and demands fix loss or damages which may be made against them
by reason of or corrrecied with the cremation of said remains as directed,whether such daims or demands are or are not whoNy
less,false or fuatudulertt.
68 Main Street, Hudson Falls, NY
1�
(Wdrtess) (Addtess)
49 Putnam Ave.
I ( 4neture and Addrew Dff Relative or Legal Representative)
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Signed on this dater� � 0 L /
Disposition of Cremated Remains
I hereby direct Pine Vlew Crematorium to dispose of the cremated remains as folbws:-
Mail to
Other arrangements-Please spec fy:
if puNwizedon of cremated rmm"is requested,check here xx
Revision:April 18,2007