Gillespie, Hertha (rnq4N OF QUEENB U9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
/,
Funeral Director CCr(t1(,
Name fle('+�s I�( Case # 3C(()
Date of Cremation
Time Cremation Started Tq: �n
Time Cremation Comple4,d
ed T SS A(�
Type of Container Lot((A ewer ►��� I E-10 CASI�
Remarks :
g.�s � �
3 q()
Town of Queensbury
Pine View Cemetery and C.rematorfum
21 Quaker Road,Queensbury, New York, 12844
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477 '
Audwizabort to Cremate
The undersigned requests and a amrtaes Phe View oematodum,In a000rderroe with mid su*d to Its Ruins and Regulations to
cremate the remains d:
Hertha Erna (vonHoldt) Gillespie F
(Marne) (Sex)
The Pines at Gler2.'1EEtFd1&a11s NY 12801-
(Stnset) (City) (State) (Zip Code)
who died on day of 08/02/2009 20_
at The Pines Glens Falls NY
TIMM) (Address)
Nome and address d noerast Imng rrtle60 or name of parsart authorizing cremation:
tvy
(Name) ( dress)
Ralatloraft to the deoaesed
Norm d Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) 5 deNbfietor,betterY,battery per,power
sew,radioactive eruptent or radioactive device in his or her body.
I cw*that I trove Till power and audwritadon so anange for the cremation of On remains end to direct the deposition of the
cremated rameirrs,that any perapnai poseessiorrs have eM o been removed or may be destroyed,end agree to prdect.date nd and
save han"Ws Pine View Cnemet slum fi+om any and an doirns and demands for ions or damages which maybe made ago!ruet them
by reason d or conrwcWd wlh the cremation d add remains as dressed whet w such dair,ts or rje- P ds are or are not whoNy
68 Main Street, Hudson Falls, NY
ne (Add
( ratue"il$
of Reiative or Legal Representative)
Signed an this dole:
Disposition of Cremated Remains
I hereby direct Pkre View Cramm"lum to dispose of the cremated remains as bNowvs�.
fl+iail to
(Uher arrangements'Please 9pedfy:
if pAmbation of cremated remains is requested,dw ck here XX
RevWxt April 18,2W7