Hack, John OF.:. OUEEP
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENS8URY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director
Name � IL U(�`` 6!—I,
k Ca se #
Date of Cremation )ice �,/qYYI N-tf
Time Cremation Started
Time Cremation Completed
y p e of Container
Remarks :
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to: 10
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Town of Queensbury
Plrm View Cemetery and Creffokw ttm
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477 '
Authorization to Cremate
The todersipned requests and autltorttea Pkre View Crematorium,In accmtsnoewkh and subject to Its Rues and Regulatlom to
cremate the remak s of:
John Harold Hack M
(Name) (SOX)
L77 Vaughn Road Kingsbury NY 12839-
Meet) (CRY) (state) (ZJp Code)
who died on 7th daYd December 20 9
at 177 Vaughn Road Kingsbury NY
(Ph") ( )
tame and address of rraareat Ih&V reikWft or trams of person aUtt OFbk g aematian:
Timothy Hack, 177 Vaughn Rd. , Hudson Falls, NY 12839
(Name) (Address)
Reiation"to the deCea9ad S o n
Name ct Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
i represent that to the best of my knowledge,the deceased(hes)6��W) ,delibdNator,battery,banery per,power
ceN,radioactK*in p ant or nmNoective device in his or her body.(
I oerfily that I have fLA power and audwrbzatlon to stamps for the cremedon of the remagns and to direct the diaposkW of the
cremated remains,that any personal poeseeskma have elhar bean removed or may be destroyed.and agree to pnAect.defend and
save harmless Plow View Crermatoritme from ary and aN claims and demands for bee or damages width may be made agoirdt them
by reason of or conrwcwd wkh t w crartmmm of sdd remains as directed,*im*w auch dams ar derrrorrds are or are not*x ft
or
68 Main Street, Hudson Falls, NY
(Adder)
177 Vaughn Road
(Sip Address of Relative or Legal Representative)
Signed on this date:
Disposkion of Cramatad Remains
I hereby direct fine View C rematorkxm to dispose of the cremated renlebw as foNows:.
Mail to
Other arrangements-Please WOW
-
If p*wkation of cremated remains is requssled,dredc here XX
FtevW:3n:AprN 18,2007