Winslow, John 4
70 OF.- QUEEN B21
-0�y
PLNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
NameTi,�,,, �„w Case # CIi1
Date of Cremation S � Z ( Z()(I CI
Time Cremation Started
Time Cremation Completed IU; j�
Type of Container C�rc �c� ;Q bier ��( F T 03T f SC
Remarks :
MAIN Mi01i
q� l
q=KZ
4
Tom of Queensbury
Pine View Cerrowy arw Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Au#Kxizadw to Cremate
The underslgnsd request and I[IN'r fees Pkte view Cremaforlum,In amordence with wO subjed to Its Rules and Regulations to
awe the remains of:
John Harrison Winslow M
(Nance) (Sex)
: 0 L.3 S} R i c _ l�a�.y.,,� !!t rci� 1 3y
(Street) (City) (State) (Zip Code)
who died on daYd 09/16/2009 20_
at 66's 6 kl py. - � C ire ice_
(Place) (address)
Name and address d neereat living rt9lOW or name of person aLdwrWng aenratlon:
jt.(ly W Ntlew /C 1116f3h:.lt
( ) (Address)
13e4819rehip to the deceased J k Y
Name d Funeral Fkxe Carleton Funeral Home, Inc.
IMPORTANT:
I repemg that to the beat of my lavowledge,the deoeesed(ttas) (has no nteker,detl fol or,battery,b per,per
cell,redkmK:lve knpierx or radioactive device in We or her body.
I oerdfy that I have*A power and audKwbztion to arrange for the cremation of the rarriakis and to dhect the dispoebm of the
cremated remains,that any Pen xmW poessesbm have eiilher bean removed or maybe destroyed,and agree to pnAact.defend and
save harmless Pk*view Crwefaitxt kart any and al claktts and demands for Idea or damages which maybe matte eaairtst them
by MOM"d or cunnecled wNh tt»c mmetion d said remakts as dk+e0ed,whether such tdaim8 ar demands are or are not whDly
groundless,ta�a Qr*audtdent.
2 ,! 68 Main Street, Hudson Falls, NY
( � ( )
and Addrese of Rei dive or Legal we)
Signed on this date:
Dbposkiion of Cremated Remalne
I hereby drew Pkte view Crema to dum to dispose of the cremated nemakrs as f allows..
M8N ID
Other arrangernerrt-Please WaXy.
If puhrer¢edon of Cremated remains is regm sled,check here XX
Revtsksm Apra 18,2007