Gilmore, George R
OF.- QUEEN5BU-r,�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
1
Funeral Director_ 6�����
Name PU�� Im�rQ Case
Date of Cremation (� Z UC
Time Cremation Started 1, 10 M
Time Cremation Completed 3 1()
Type of Container �r�� ��� �,l'pPp W(Ov) At&
Remarks ;
MAIN 1- L6 mo�� i� �t)
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Ofte: (518)745-4476, Crematorium: (518)745-4477 '
Authorization to Cremate
The undersigned requests and sufhortass Pine View Crenu tarlum,In accordence with end subject to Its Rules and Regulations to
cremate the remains of:
George Dudley Gilmore M
(Name) (Sex)
7.1 Maple St Hudson Falls NY 12839-
(Street) (Cky) (State) (ZIP Code)
who died on 14th d9ycl September 20 1
at Glens Falls Hospital Glens Falls NY
(Place) (Address)
Name and address of on met living robs"or name of person suthorb tp cremation:
Mr. David N Gilmore 4170 AIT Taipei Place, Dulles, VA
(Name) (Address)
Retatlortsltip to the deceased S on
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the beet of my knowledge,the deceased(tree a(has rto eked,del bribtur,battery,battery peck,power
oaf,radioactive implant or nK§oac dm dnsvka In his or her body. )
1 eerdfy that 1#rave U power and au tortmtion to arrange for rite cret wkin of the remmins and to dines the disposition of the
awnateci remains,that arty personal poseeesk ns have eMo bean removed or may be destroyed,and agree to protect,defend and
save hemNess Pine View CnemalwWm from any and all dsiras and dentartds for foes or domaps which may be made egont thorn
by reason of a eo wmc Wd wkh do cuerrtatim of saki nem*m as dkWod.try wdmN suds daims ar darrrartde are or ante not wholly
68 Main Street, Hudson Falls,-,NY
D (Address}
ulles, VA
(Signature on Address of =ilra or Leo RepresentetI've)
Sept. 15, 2009
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine Vlew Cmuslakn to dispose of the cremated renwins as follows:.
Mail to
Oaten arrangements-Please specify.
If pAierlWion of cremated remains is requested,dteclt here XX
Rw4ision.April 18,2007