Archambault, Laverne A •
• TOWN OF QUEENSBUIU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name [Auer rc���, � (�- Case #
Date of Cremation I ebrvc,r Z 700
/,
Time Cremation Started I2% IS:P
Time Cremation Completed 2 .30 Tri
Type of Container („,c(Goa,i Ct2ALv FORD SKCO10 C{�
Remarks :
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01123/2010 14;35 5184991R50 JJLLS FUNERAL HOmE P v
AGE 03
• L�y
Town of Qusensbury
Pins View Cemetery end Crematorium
21 Quaker Road,Oueensbury,Now York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745.4477 •
Autltoriaatton fo Cremate •
The underaipned rearms and fertextices Pine VW*Crematorium,in accordance with wed aub}ee t to es Rubs end,Rrpultbns to
ornate tha wore eat:
Laverne A. Archambault Female
(Name) . (fro
180 Abaire Road Whitehall New York 12887
(stroet) (pry) • Mate) (Zip Code)
w riddied on 26 th drat January z 10
ae Rutland Regional Medical Center
(Piste) (Address)
Norris and address oi newest event rete+evs ahem of person authorizing awnsnurc
Stewart Smith 21R GrEtnne Stre$t Bristol cT 96010
(Nen* (Address)
inardp to the deceased . Son
Name ral Figwort Homo Jillson Funeral Home Inc.
IMPORTANT:
i ibpresert Mid to t twat of MY iaheiedps,the deamaed(hoe)or(has no)pacemaker,de brillator!tweedy,bowery pack.power
ate.tmdloeWve tinplate or rsalioetitive tieait^s in his or her body.(drde One)
I certify that I Mrs tulptorar endwithOrtastast to anew for the aevndan of the remote and to direct Me otspositian of the
rn rnated ram;that ewy Memel poas+w0one tuna stirrer been renhoee3 or may to dasaoyed,mid earns to etched defend and
earl Mtrniess Pins View Clsethstonunh from m+y ached ad Oats end demande for toes or demean vh*kdt mite made against deem
tit ninon of or m,neded weh the aemation of sold remelts is directed.ettetlair such delms or demands ere or ens no wholly
grotxtdiess,false or>reutkrient.
4,
iitscirge.sbitr6
( end Address of Relative or Legal RRapreer hp e)
Stewed on ens date: Jan. 2 8, 2 010
t)tapoaitiors of crsmsted Romaine
t rwreby einem Pins Vtstr Overatorturn to dispose of tt to oemprd moslns she
Mr. Steven Smith 218 Greene St. Bristol Ct. 06010
mas to
Other er'rsnpemerhs-Piedss specify;
if duly Megaton of cremated remakes is requested chetah here_
rof
RoditO A:Jeremy 1.20t10