Fordrung, Christina TO`14 O fF QB'uj
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director (rIttc,
Name C i
Forctru) Case # 5-01
Date of Cremation � A�►uc)r.� (I 7
040
I
Time Cremation Started 1' 3 ) /An
Time Cremation Completed 9:'cK �M
Type of Container /j,cit caret 1c' - Pdi r,,st C4-4-(
Remarks :
A h 140v6 g "4ti
110 an
e , 30647
Town of Queensberry
•
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains d:
Christine. Fordrung Female
(Name) (Sex)
ey /01,,
} (zip Code)
who�Ot day of 12/21/2009 20 pr3
Glens Falls Hospital Glens Falls NY
at
(Place) (Address)
Name and address of nearest living relative or name of person atthortring cremation:
George Fordrung
(Name) (Address)
Relationship to the deceased S o n •
Name ot Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no) maker,defibrillator,battery,battery pew,power
cell,radioactive implant or radioactive device in his or her body.(C
1 certify that I have full power end authorization to arrange for the cremation of the remains end to direct the dieposidan of the
cremated remains,that any personal possessions have etster been removed or may be destroyed,and agree to protect.defend and
save harmless Pine View Cre netOriun from any and all dates and demands for loss or damages which may be made against them
by reason d or connected with the cremation of said remains as directed,whether such dames or demands are or ere not wholly
groans, or
_yitra.
68 Main Street, Hudson Falls, NY
(Address)
�rz
(stg end Address of Relative Representative)
Signed on this date: 1 L'ti'l c°1
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains es follows:.
Mull to
Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here XX
Revisiorc April 18,2007