Roberts, Ralph TO(KN OF QUEEN,5BU_1ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 0d 1?` ) <U1v
Name l ��CpH &b.-FT VS Case #
Date of Crematicn
Time Cremation Started / <,3
Time Cremation Completed 'It "/x � (
Type of Container 4�&P&YIR� �s /, L,/�J�i� Q� T//,�o��
Remarks :
/41 Ai N `.,l yd d/M '
1416 ZE2 :5111'a &M -
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1� I/ ,�i.3si9�w► a
TOWN OF QUEENSHIJRY
PINE VIEW CEMETERY
a
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUT1-1ORlznrtUN TO CREM/1TE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of :
Ralph Edgar Roberte _ Male
(Name) (Sex)
3 Laurel Road Moreau, NY 12828
(Street ) (City) (State ) ( tip Code)
who died on ^tit day of 1„14, 19 97
at Hngp;ta„ 100 Park Street Glens Falls, NY 12801
(Place) (Address )
Name and address of nearest living relative or name of person
authorizing cremation :
Frances H. Roberts 3 Laurel Road Ft . Edward , NY
(Name) (Address)
Relationship to the deceased Wife
Name of Funeral Home Carleton Funeral Home Inc.
IMPORTANT:
_I r r
____onv_sa^}__tha-t to the best of my knowledge, the deceased has or
has no pacemaE<e in his or her body. (Circle One)
I certi y 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
6J
group s, ` lse �or fraudulent.
"C-��' l Carl eton Fnnaral Home , Inn
(Witness) —� (Address)
mac_� x Fort Edward , NY
(Signature of Relative or Legal Rep. and Address)
Signed on this date :