Goodspeed, Kathleen •
s�'��� OF
TOWN QuEENsBu.�Y
Pine Viet, Cemetery and Crematorium
11 Quaker Road, Queenshury, NY. 11804.5902
(518) 745.4476
http:i/WWW,queensbu (518) 743.4477
ry.net
Funeral Director:
Name of Deceased: Ke,11,
Case Number: Z
Date of Cremation: ,j�,A4
Retort:
Time Cremation Started: C ''
Time Cremation Completed: lc; •
Type of Container:
�'1 Cis
Remarks:
N
1
lc: iv
" Houle of Natural Beauty ... A Cool( Place In Live "
IT 255
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 a000rdanoe with and subject to its Rules and Regulations to
cremate the remains of:
"1/{1I-(z � s✓�s�5 ' D Female
(Name) (Sex)
Ridge Road Queensbury New York 12803
(Street) (may) (State) (Zip Code)
who died on 27 day of
January 2008
at Adk. Tri-County Nursing Home & Rehabilitation Ctr .
(Place) (Address)
(johnsburg, NY)
Name and address of nearest living relative or name of person authorizing cremation:
Ronald Goodspeed 2383 Ridge Rd. Queensbury, NY
(Name) (Address)
Relationship to the deceased Husband
Name of Funeral Home Alexander-Raker FiinPral Howe
IMPORTANT: -
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,dellbriilator or any other battery operated
device in his or her body. (Circle One)
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remai possessions have either been removed or may be destroyed,and agree to protect,defend and
save ire View Cue um from any and all dams and demands for loss or damages which may be made against them
by of or connected the cremation of said remains as directed,whether such claims or demands are or are not wholly
g less,false or lint.
Warrensburg, NY 12885
fitness) (Address)
A 40 • 2:4 d - e -
(Signature and Address of elative l Representative)
signed on Ms date: May 2 9 , 2008
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
mad to funeral home will pick up.
Other arrangements-Please specify: —
If pulverization of cremated remains is requested,check here X
Revision:J ijy720G4