Winney, Robert OF QUEENBU 9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
i Funeral Director I
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queerhsbury,New York, 12804
Cemetery Office:(518)745-4476,Crematorium:(518)745-4477
Authorization to Cremate
The hrhdersigned requests and auftmes Pine View Crematorium,in accardancoe with and subject to fts Rules and Regulations to
cremate the remains of•.
Robert Winney M
( )
2500 Statekk lqq, Fort Ann NY 12827-
(')06/19/2006 (City) (State) (Zip
who died on day of 20_
Glens Falls Hospital Glens Falls NY
at
(piece) ( )
Name and address of neared going relative or name of person aL*mdzlrhg crerthaton:
Mrs. Betty Winney 2500 State Route 149
(Name) (Address)
Retatormhip to the deceased Wife
Name ofFurmatMorrhe Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the beet dray bhoaiedge,the deceased(has)or(has no)pacenhe1w,del b RaW or arty other battery operated
device in his or her body. (Circle One)
1 certify that 1 have fu1 power and authortimtbrh tD amsrw for the cremation of the►emeft and to direct the disposition of the
cremated remains,abet any personal possessions have either been remcmed or maybe dedrayed,end agree to protect,detbnd and
save harmless Pine View Cremetorfrim from any and at dshro and derma for loess or damages which may be made ageirial them
by reason of or corrected with the uematorh of said rernairis as N a ri 4d,whalher such deems or dar=KM are or are not wh*
or Ebless)K(V (Address)
(S a and ^ evg�alR�epeserttathre)
Signed on this date: J l.� Y1 'L- d� , a 60y 0
Disposition of Cremated Remains
I hereby dired Pine View Crematorium to dispose of the cremated remains as f glows:
Map to
Other arrangemar*s-Please specify:/I efu,C�✓ 7Cp_4u1v<L.4/
if puNwkEation of cremated remains is requested,check here XX
Revision:January 1,2006