Smith, Robert T074N OF" QUEEVBU-' Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director�� /�� lfJ�"
Name / 1�� /l w ! isY Case #
Date of Cremation
Time Cremation Started
Time Cremation Completed?134 /
Type of Container
Remarks :
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TOWN OF RUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Rueensbury, New York 12804 .'
Phone (518) Crematorium 798-4726 or if no answer Cemetery;793-9777
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:
Name Sex
Street City State Zip Code
who died on day of 19
at
Place Address ——
Name and address of nearest living relative or name of person authorizing cremation:
Name Address
Relationship to the deceased
Name of the funeral home
IMPORTANT:
1 represent that to the best of my knowledge, the deceased has or has no pacemaker in his
or her body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of the
remains and 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 loss or damages which
may be made against them by reason of, or connected with the cremation of said remains
as directed, whether such claims or demands are, or are not, wholly groundless, false or fraudulent.
Witness ---------
(Signature of Relat ve or Legal Rep.
Address Address
Signed on this (late
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
AUTHORIZATION TO CREMATE
Tlie undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulations to cremate the remains oft
Robert E. Smith
Name male
(Be
1 Chestnut St . , Hudson Falls ,
Street NY 12839
City State Zip Code
who died on 20th
day of March 19 94
at Glens Falls Hospital, Glens Falls , NY
Place Address __,
Name and address of nearest living relative or name of person authorizing cremations
Mrs . Helen Smith . 1 Chestnut Dr.
Name , Hudson Falls, NY
Address
Relationship to the deceased
spouse
Name of the funeral home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has �hasno
acemaker in his
or her body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of th
remains and to direct the disposition of the cremated remains, that an e
y personal
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 loss possessions
may be made against them by reason of, or connected with the cremation of said remains
as directed, whether such claims or demands are, or are not, wholly groundless, false or fraudulent.Pj
uduient.
Witness
S gnature o Relat ve or Legal Rep.
Carleton Funeral Home, Inc
Address 1 Chestnut Drive
Address
Signed on this date Hudson falls, NY
ZL