Plude, Theresa r -
Off. QUEEN5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �P���,�
Name � 2Ia41- Case # 3VI
Date of Cremation Sepfov,%�e ' (( f 7065
Time Cremation Started gyp: Uu At-)
Time Cremation Completed 16`. °b
Type of Container ac-c�Log rJ y=1 a�0 CAS �
Remarks :
M A:PN - IS ft tj r moues Sl qZ tin
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Town of Queerlsbury
Pine View Cemetery and Crematodum
21 Quaker Road,Queensbury, New York, 12804
Cemetery QNice: (518)745-4476, Crematorium: (518)7454477 '
Aut xx1za* h to Cremate
The undersierted mquffift and U*Mrtbes Pkte View Crematarkum,In aowrdarm with end subjed to its Rules and Regulations to
cremate the temaUts d:
'j-' resa Plude M
(Name) (Seat)
'Broadway, Fort Edward, NY 12828
— (Street) (City) (State) (W p Code)
mftdiedon the 2nd dayd Sept 20 9
at FORT HUDSON HEALTH CARE FACFort Edward NY
( ) ( )
Name and address of non met living rehove or name of person audxWtz ng taerrteAiort:
Pam Q,"A& — )I5 aa,n
(Name) (Address)
ReWdonehip to the deaesrad 4ZL i_!
Name d Funeral 111m, Carleton Funeral Home, Inc.
IMPORTANT
epaetht to h bes d:my aowedge the oes+ds debrleo ,befty,bommY Pam tyre
cep,nedioactive imptent or nm9oecslva device In his or her body.(
l ov*that l have full power and suamdeetlon to anarpe for the cmmellon of the rerna is and to direct the dlepoenm of the
crarfinead rerrteirte,that arty personal poseveekM have aMmr been removed or maybe desboyed,and agree to prated,defend and
save hern*m Pine View Cremel*kim from tsty and all dalrtrs ewd derrtends far rasa or damages vA dd may be made o0w at d"m
by resson d or o nrrgrip wk h tf to crvmedm of acrid nemelrts 65 directed,wftedter such dGhl or de= jA are Or ere riot wholly
Wou,Exam
.1198
68 Main Street, Hudson Falls, NY
(yytf ) (Address)
n,o zk ) &Q -
(Signature end Address of ReWm or Legal Represersative)
Signed on this date:
DispooWn of C mmated Remeire
I hereby direct Pine view tanatorlum to diepose of the cremated remains as Wows:.
Mail to
Oem arrangements-Please epedly:
if ptriveraatian of Cremated rents m is requested,cte&here XX
Revhkxt:April 18,2W7