Streeter, Leonard Franklin h ,
TOWN OF QUEENS'BUIU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name l,tpnArc/ 61 rie,t-e( Case # 1L
Date of Cremation Fez) IL lOib
Time Cremation Started DU A
Time Cremation Completed fU : 1-10nti
Type of Container f
190,,7 -PC II, (51-CCSe
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:
Leonard Franklin Streeter M
(Name) (Sear)
1.34 Burke Drive, Ctiusielidals,mr NY 12804-
(Street) (City) (State) (Zip Code)
who died on 10th day of February 2010
Glens Falls Hospital Glens Falls NY
at
(Place) (Address)
Name and address of nearest living relative or name of person authorizing aeration:
Michael Lyons 16 Frederick Dr. , Saratoga Springs, NY
(Name) (Address)
Relationship to the decked S o n
Name d Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibreator,battery,battery pad:,power
cell,radioactive implant or radioective device in his or her body.(Circle One)
1 certify that I have full 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 Cretaetaattme from any and ail claims and demands for loss or damages which may be made against them
by resson of or connected with the aentetion of said remains as directed,whether such claims or demands are or ere not wholly
77177false or heudulent.
,,,c)_____„( 68 Main Street, Hudson Falls, NY
(
6 Frederick D )rive, Saratoga Springs, NY
��Y� Ar
t? ,nature/AL Address of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as f llowr.
Mail to
Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here XX
Revision:Apia 18,2007 •