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Porter, Donald Carl • TO T1 N OF Qi8 VL r,P`^ PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURy, NEW YORK 12804 (518) 745-4476 (518) 745-4477 uneral Director ( ie�� Name Vo,q101 roriPC Case # �5 Date of Cremation Fel9 IL I Z01b Time Cremation Started � " O S Time Cremation Completed 10" 45 (fir Type of Container ( 1rc)bvur� G(ZAWFO2I9 t IeSt C s s[ Remarks : tiftrk iti itiou6 ¶IO7j 5' Sofih ((yIS /911 • 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 Rubs and Regulations to aemate the remains of: Donald Carl Porter M (Name) (Sea) 5.67 Buttermilk Ffi'hds Iliad NY 12827- (Street) (City) (State) (Zip Code) who died on day of 0 2/0 7/2 010 20• Residence Fort Ann NY at (Piece) (Address) Name and address of nearest living relative a name of person at1horiartg cremation: Carol Porter 567 Buttermilk Falls Road , Fort Ann, NY 12827 (Name) (Address) Relationship to the deceased Wife • Name o►Funeral Home Carleton Funeral Home, Inc. IMPORTANT: I represent that to the best of my knowledge,the deceased(has) pecemaker,del8xiletor,battery,battery per,power cell,radioactive implant or radioactive device in his or her body.(C ) 1 certify that I have full power and 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 Crematorium from any and all claims and demands for loss or damages which may be made against them by r©12:4,„. ason of or cremation with the amation of said remains as directed, such claims demands as or are or ere not wholy r or /. � 68 Main Street, Hudson Falls, NY (Address) 567 Buttermilk Falls Road, Fort Ann, NY ( and Address of Relative or Legal Representative) Signed on this date: Z.- I 0 Dispoekion of Cremated Remains I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:. Mail to Other arrangement-Please specify: tf pulverization of cremated remains is requested,check here XX Revisiort:April 18,2007 • J