Dufore, Marghueritta TO q+N OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name dcl(i �Jerl Nc% o(,t Case # 331
Date of Cremation
Time Cremation Started
Time Cremation Completed 10'�5
Type of Container 4frLAIJ
Remarks :
MAIN �1 lS N1 moves to: 05'A tj
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33�
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477 '
Audwrization to Cremate
The undersigned request and sudtoniaes Pine View Cranatartum,In accordance with end subject to Its Rules and Regulations to
cremate the remains of:
Marghueritta Adrian (Roberts) DuFore F
(Name) (SOX)
Pleasant Valley HCF Argyle NY 12809-
(Shim) (City) (State) (ZJp Code)
who died on 3 0 t h day of July 20 0 9
at Pleasant Valley HCF Argyle NY
(Place) (Address)
Name and address of nearest living relative or name of person auMormng cremation:
Peggy Leombruno, 6 Chestnut St. , Hudson Falls, NY
(Name) (Address)
-
Reiatioreft to the deceased Cousin
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the bast of my WWWk dge,the deceased(has)or(tree rho)pacemaker,debrilla[or,battery,battery lam,power
cep,rndloective implant or radioactive device in this or her body.(Circle One)
I owtify that I have Thiel power and&UftWbZUDn to arrange for the cremation of the remains and to direct the disposoian of the
cremated rwnskm that any personal possissione have eOw beech removed or may be destroyed,and agree to pnxecL defend and
savgAwftss Pine View Crematorium from tarry and all Maims and demands for I=or damages which may be made against them
by or connected with the cremation of add remains as dk eCU4 whether such chime or demands are or am not v t*
false or*wr. .
ain Street, Hudson Falls, NY
(ma's)
X 6 Chestnut St. , Hudson Falls, NY
(Sig and Address of Reiatim or Legal Representative)
7/31/09
Signed on this date:
Disposition of 0amated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as Wows:
Mail to
Other arrangements-Please specify:
tf pulverization of cremated remains is requested,die&here XX
Revision:April 18,2007