Rice, Charles (o`14N of QUEEVBU-0�y
PINE VIEW CEMETERY AND CREMATORIUM`
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
1
Funeral Director
Name ,�hf��S �� � Case #
5 31
Date of Cremation I�ef��, b, �� ZUO�
Time Cremation Started A h
Time Cremation Completed IU 5S A1�
Type of Container ��.ri .17yci�{,� I'v�nlC� c� ,r• t C�s�
Remarks :
��r�► y� A 010v6 T3C At7
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium; (518)745-4477
Auk to Cremate
The undersigned requests and aulhortms Pkte View Cremeat wium,in accordance wkh and suttjed to its Rubs and Regulations to
cremate the remain of:
Charles Clare Rice M
(Name) (Sex)
The Orchard Granville NY 12832-
(Shim) (CRY) (State) (zip ram)
vrho died on day of 12/11/2 0 0 9 20_
at The Orchard Granville NY
( ) ( )
Nerve and address of naarast livhrg r+eletiva or name of—d -n at thorb*w cremation;
Mrs. Roberta Clute "p , Z ' TO W erS
( ) ('�M) Queensbury, NY 12804 I CSO�'l y'
Ito ft Friend la` &3q
Name d Funeral tkxw Carleton Funeral Home, Inc.
IMPORTANT;
l represent that W Hte best of my lawwledge,the doceaaed(has)a(has nD)pecemeksr,deftaator,be",balJoypedcpmer
cell,radlaec th*Implant a nK*oacrive device In his or her body.(Ckde one)
I oar*that I lava full power and aWwrketlon to arracpe for the cxemellon of the ramsine and to duet t the dieposelon of the
cremated remalne,that any personal poeseaskme have egret been removed or may be dea0'oved,and agree to proleGt,defend and
save harmless Plea View Cntr nlarium from anyr end eN loll,s and demands for im a darrragea which maybe made agog a t them
by reason of or car wcted whit the cmmadm of add re makm as d recled,whether suds derma or da, a,do are or are not wholly
68 Main Street, Hudson Falls, NY
(Aftew)
(SVuMxd and AdOmw of Retatiwa or Legal Representative) f S i
Signed on this date:
Disposkion of Crameted Remehie
I hereby direct Pine View Crematorhxn to di8pose of the cremated remain as follows:.
Meal to
Ckher arrangements-Please speciry-
If pulverization of cremated remains is requested,d &here XX
RCvWkn April 18,2007