Clarke, Leeanne • e
TOWN OF QcB QL J
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 1‘.,
Name te(A,Ine ���%r Case #
Date of Cremation b It) ZOIO
Time Cremation Started X is ILI
Time Cremation Completed 10 • 00 fin
Type of Container (;„-ILo.;,c' £l2-1;1A/F(j; .1
Remarks :
h b 'h itiOu 1;6° 1111
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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•
Authodzation to Cremate
The undersigned requests and authorises Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
Leeanne Clarke F
(Name) (Sec)
L7 Pearl Hudson Falls NY 12839-
(Street) (City) (State) (Zip Code)
who died on day of 02/17/2010 2010
Glens Falls Hospital Glens Falls NY
at
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Alex Clarke
(Name) (Address)
•
Relationship to the deceased S o n
Named Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) no) ,defibrillator,battery,battery padc,pow
cell,radioactive implant or radioactive device in his or her body.(
I certify that I have fill pow 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 toes or damages which may be made against them
by meson or or convected with the aemetion of said remains as directed,whether such claims or demands are or are not wholly
grvundleas,false or fraudulent.
68 Main Street, Hudson Falls, NY
(Witness) (Address)
(Signature and Address of Relative or Legal Representative)
Signed on this date:
•
Disposition of Cremated Remains
I hereby died Pine View Crematorium to dispose of the cremated remains as follows:.
Mail to
Other arrangements-Please specify:
ff pulverization of cremated remains is requested,check here XX
Revision:April 18,2007