Havens(Yule), Marion Lorraome •-•
• TOTIN OF QUEENSBUIU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Cr1tu
Name 1 lc,{10L-- ti��h5
Case # 21
Date of Cremation c,,wc,.-y/ 20 7010
Time Cremation Started
Time Cremation Completed l0 II() \f'l
Type of Container L4rel oc,o+ A -1201-e` P1( Flrst65e
Remarks :
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Town of Queensbury
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 of:
Marion Lorraine (Yule) Havens F
(Name) (Sex)
4 Fairview Lane Kingsbury NY 12839-
(Street) (City) (fie) (Zip Code)
who died on 16th day of January 2010
6 Fairview Road Kingsbury NY
at
(Place) (Address)
Name and address of mare*living relative or name of person authorizing cremation:
Sheila Patten 10 Boulevard, Hudson Falls, NY
(Name) (Address)
Relationship to the deceased Daughter
Name d Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the beet of my ta►vwledge,the deceased(hes)or(has no)pacemaker,defibrillator,battery,battery pedc,power
cell,radioactive implant or radioactive device in his or her body.(Cade One)
1 certify that 1 have fill power end authorization to arrange for the cremation of the remains end to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Cneriretorium from any and aN claims and demands for loss or damages which may be made against thorn
by Meson of or connected with the aernation of said remelts as diected,whetter such debits or demands are or are not wholly
or
68 Main Street, Hudson Falls, NY
O (Address)
oulevard, Hudson Falls, NY 12839
(Signature and Address of Relative or Legal Representative)
Signed on this date: Jan 17, 2010
Disposition of Cremated Remains
l hereby direct Pine View Crematorium to dispose of the cremated remain as follows:.
Mail to
Other arrangements-Please specify:
if pulverization of cremated z mains is requested,check here XX
Revision:April 18,2007