Cleveland, Robert SOWN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director z V* R
Name Roy � � � VA- Case # �
Date of Cremation lLC6 - Q �t
Time Cremation Started 1 ��
Time Cremation Completed
Type of Container OA-(ZD ojm(-17z) C � GRy ) e'
Remarks :
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TOWN OF QUEENSSURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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:
Robert James Cleveland Male
(Name) (Sex)
119 So. Ike Hayes Rd. , Brant Lake , NY 12815
(Street) (City) (State) (Zip Code)
who died on 21 day of Dec. 19 99
at Glens Falls Hos. , Glens Falls, NY
(Place) (Address )
Name and address of nearest living relative or name of person
authorizing cremation:
Phyllis M. Cleveland, Same as above
(Name) (Address)
Relationship to the deceased Spouse
Name of Funeral Home Alexander Funeral Home, Warrensburg, NY
IMPORTANT:
I represent that to the best of my knowledge, the deceased A)SA5)M
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
direc , whether such claims or demands are or are not wholly
gro dles , false or fraudulent.
Warrensburg, NY
—(Witness.) (Ad ess )
f
(Si atuze of Relative or Legal Rep. and Address)
Signed on this date: 12-21-99