Grosse, John OF. QUEEN,5BU9Zy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �'"14,-
NameL—'1115-sle Case # W)
Date of Cremation Sege'.,6-w
3 ZUQ
Time Cremation Started 12 !YU
Time Cremation Completed
/1 I FF
Type of Container C�r��Jca21 C2��Wrd�Q Sr("OMo CALF,
Remarks :
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Tom of Qummsbury
Pine View Cerrelery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Oftiae: (518)745-4476, Crematorium: (518)745-4477 '
Audwrization to Cremate
The undersigned req mft and audwdzes Pk*View Crearatodum,In accordance with and sutied to fts Rubs and Regulations to
cremate the remsirre of:
John Bernard Grosse M
(Name) (S"
The Stanton
(Street) (City) (Stare) (ZJ p Code)
vft died on day of 09/01/2009 20_
at Glens Falls Hospital Glens Falls NY
(PISM) ( )
Name and address of+hoarse[IWbV retative or name of person audxwbtng aemadon:
Sandy Stickney 9 Arbor Drive
(Name) (Address)
Refedonshlp to the tbCeeaed Daughter
Name ofPuneraiiiane Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of ny tawwkKV%the dooeasad(thee) nheker,dekwNeW,battery,batten+parr,power
ceN,mftecdve imptent or raftecOw device in his or her body.(CnW )
I cerWy drat I have U poww and audxwb t w to arrange for the creme0on of the remaft and to dived the dispoeihan of the
cremated remains,that arty personal possessions have elthar been rarrhoved or may be desheyed,and agree to pnXed,defend and
save ha ntbas Pine View CnemotOrtum ftm arty and sll debts and demands for hies or do -ages wfiCh tray be made against them
by roam of or o mecwd wish the caer wdm of add temek s as dkw!Ied,whether such ckdnha or dertiarrtls are or are not wholly
wound as,Was
68 Main Street, Hudson Falls, NY
�� (Address)
9 Arbor Drive
LA
(Signature and Relative or[_spat RepressnWlve)
Signed on this dale:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of V*cremeled tenw9m 081011MA:.
M811 to
Other arrangements-Pleese specify:
ff pAwrWMon of Cremated remains is requested,dw&here XX
RevW=AprN 18,2007