Roberts, Myron r �
rrO q+N OF QUEEVBUP,..Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directorrl�
Name d (g. Case #
Date of Cremat i cn zg
t
Time Cremation Started !f /►'�j / /191
Time Cremation Completed
Type of Container
Remarks :
141 A N 'G01?1 R-'q Pf
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rrc rUl`ICKHI- MUFTI- Z31t;48978-IS 4 P.02
0001
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FROM ALEXANDER FUNERAL HOMES PHONE NO.
Dec, 19 1997 1O:43AM P1
:t
4
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TOWN Or OUEE'NSRURY
PINE VIEW CEMETERY
i
CREMATORIUM
Quaker Read, Queens.bvey, Now York 18804Nil
PhOnO (518) Crsmatbrium 745-4477 or if no answer
Cemetery 745-4476 ,
'AUTNORIZOTION TO CREMATE
The l,nslersigned requests and authorizes Fine View Crematorium, in
aceerdance with and subject to its Rules and AegulatiOnL to
cremate the remains of=
-Myron R. Roberts
Male
(Name) lSeK>
21 Atateka Dr. Chestertown, N1Y
($treat) (City) (8tabe7 (Zip Codaf tiff
who died 4n 19day of 1497 19�
at s er N
(Place) (Address)
Name and address of nearest duthor•iling cremations living relative or name of
Person ;�
�vqr
(Address) .=mod✓.�.y y �i;p�i
Rely to the
Relationship a deceased00
Name of Funeral Moue /��-' yE/(,'��
IMPORTANT: N
I represent that to the best of my knowledge, the deceatiea r
has no pacemaker in 'h'is or her body. (Circ'le One)
1 certify that 1 have the full powRr and authorisation to &,,range
for the creaatinn of the remains and to direct .tho dispoaitlon .of
the Cremated remains, that .any Rorional pgsSe' s ions have ether
I+
been removed or may be ' destrayed, 4rdl agroo,' to ' prQtrrct, defsntl
am slave harmless Rine " View Crematorium from any and , all claims �ahf and doaands for lost ar damages which may be' made ape►i�st then by reaspn -of or connected with the Cremation of said remains as directed, whether such' Cf,iims or •detmands arm.-vbr' d►1►'a;:.not wholly
roundlesa, false or fraudulent