Rosenberg, Robert OF QUEEVBUPy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
L Funeral Director- MI R � �� f J
Name OPtr- R1AC-e jYbere) Case#
Date Of Cremation 0C
Time Cremation Started
Time Cremation Completed
Type of Container_ CA MA C/45P- (VTzn �
Remarks
r � �
Towr of Queensbury
Piste View Cc.-netery and Crematodu
21 Quaker Road, �.Iueensbury, New York 1 ?804
Cemetery Cffioe• (518)7,44476, Crematorium ,5 i B)745-4477
Authonzation to Cremate
The widersigried rF Guests and authorizes Pine View Crematorium, in acoordar oe .ith and subject to its Rules and Regulations to
cremate the remains of!
Rooc rt iosenberg Male
(sex)
Vale Have,, Hon ._ for Adult's Pen, NY
at) (C,ltyi (state) (Z;p Code)
who c ad on 'he tenth
— _ ---- x) --- day a -May-- 2t308
at.- Che,pla, .Aey Phyercians Hospital P'wttsburgh, New York
tPlace) (Address)
Name an I tddres . 0 nearest living relative or name o`person authorizing crf ,nation:
Fred Rot:- iberg 460 501^ Street, Srookil,,t, NY 1127C
RaIabooin,,!o the dE�,,easeo
N; ;ne of F(n®of Home M. S. Kilmer Fun :ral Home
i r'ewes. it that u,the ,est of my knewiedge,the deeeaseA(nest)a as n0 l.: ,emakdr,nel'ItAlator or any other bartery opereted device in nis or her body.(Cade
One)
i certd hat l hove ft d power and authorization.o Arrange for the rematlr n or ie rem nns and to direct the dit:position of the cremetnd remains,that any perxonai
posse $ions have a her Deep. removed or may be Gerstroysd,,,n• agree,o pr( :ect,A ,rend and save harmless Pine Viewrrornatorium f vni any and all oil ims
and( rnarids for I(A*or damages which maybe mode P9amst ti-orn b.reae(n of( .onnected witn the cremation or said remains as directed,whether such
uain or dernan:s.re ar a Nt,r;'y growatex9, Fa;se of ri .,ur.ule.,t
,� t om - • ----- - i O :� Sd` /� CC.�rry /f% /AA v
,d tress)
Y
(S nature and Address of Relative r I.- Sal R_eprrsentati,.
Signed on this date: 1 6
Oisposltion of remated Remains
hereby direa Pine View Ciemstorium to dispo"r w c•iernated rgntGirrs as 'oll,ws
Other arrangements-Please specify Fw,er Mome will r,.._
!f Du Iverization of crernated remaaas is requk.ste..c :k here-__--_
Rev,@gn January ;:0!)b