Lord,(Coleman), Aria C TOWN OF QQJEAJ8 K
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 71- Ie+
C Vr.
Name Ytf15 ` `J Case #
Date of Cremation hff b l9 7OIC
Time Cremation Started jc 0
Time Cremation Completed 10 . i()
Type of Container `6,44,;,lvd ( _ cFirs r
Remarks :
h Pa c /� h vv6 `I- 9 h
91
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 reorients and authorizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of:
Aria C. (Coleman) Lord F
(Name) (Seoc)
Pleasant Valley SNF Argyle NY 12809-
(Street) (City) (State) (Zip Code)
whodiedcn the 18th deYo February 2010
PLEASANT VALLEY NURSING FACArgyle NY
at
( ) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Mrs. Nancy Breeyear 564 Lower Oak Street
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT: (,
l represent that to the best of my knowledge,the deo ease w or(hes no)pacemaker,defibrillator,battery,battery peck,power
cell,radioactive implant or radioactive device in his or her r(Circle One)
1 certify that I have full power end authorization to arrange for the aemoli4n of the remains end to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,end agree to protect.defend and
save harmless Pine View Crarpetortlim from any and all dawns and demands for foss or damages which may be made against them
of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
false or
68 Main Street, Hudson Falls, NY
( ) (Address)
O ,564 Lower Oak Street
6)17
Relative LegalRepresentative)(� Repreaentet )
Signed on this date: 2' 1 Cr— 1 D
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as folbws'.
Mail to
Other arrangements'Please apeolfy:
if pulverization of cremated remains is requested,dredc here XX
Revision:Aprl 18,2007