Gadway, John Joseph TOTIN OF QUEENS'BU2U
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name o - t ,ri,
Case
Date of Cremation itb
Time Cremation Started
Time Cremation Completed
Type of Container clA �;
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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:
John Joseph Gadway M
(Name) (Sex)
1659 State Route 9, Lot 28 Moreau NY 12803-
(Street) (City) (State) (Zip Code)
who died on 18th day of February �01
Glens Falls Hospital Glens Falls NY
at
(Place) (Address)
Name and address of nearest living relative or name of person authorizing carnation:
Deborah Gadway 1659 State Route 9, Lot 28, S. Glens Falls, NY
(Name) (Address)
Relationship to the deceased Wife
Name oft Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
1 represent that to the best of my knowledge,the deceased(has)�pacemaker,defibrillator,b, batterypeck, ower or, y, ,p
cell,radioactiveimplant or rathoac hive device in his or her body.( )
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 ail dales and demands for bile or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such dales or demands are or we not wholly
V:s.
false or fraudulent
nnefo.;• 68 Main Street, Hudson Falls, NY
���� (Witness) (Address)
Mate Route 9, Lot 28, S Glens Falls, NY
(Signatcseankt Address of blues or Legal Representative)
Signed on this date: % 1 `', i
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:.
Mail to
Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here XX
Revision:April 18,2007