The URL can be used to link to this page

Rose, Robert (ogtiN OF QUEE��5BU�Ky PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 --� -}- Funeral Director /��l�Lly -I (� aTe ©��1� 1 �S ----,�--' � Case,: 2_ J� � Date Of Cremation T ':me Cremation Started T ! Me Cremation Completed T''p e 01 Container ��jq y �• �,r�-�GK1Sb�{=,�- Ul Remarks ILI ae) IL j TOWN OF QUEENSBURY '�1 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 Jack Rose Male (Name) (Sex) Main St. Port Henry,NY 12974 (Street) (City) (State) (Zip Code) who died on 12th day of September 2003 at Moses Ludington Hospital Ticonderoga,NY 12883 (Place) (Address) Name and address of nearest living relative or name of person authorizing cremations: Harold J.Rose 3139 West Gettysburg Ave., Fresno,CA 93722 (Name) (Address) Relationship to the deceased Brother Name of Funeral Home Carleton Funeral Home,Inc. IMPORTANT: I represent that to the best of my knowledge, the deceased has or h�sn 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 directed, wheth such claims or demands are not wholly groundless, false or fraudulent. c68 Main Street P.O.Box 67, Hudson Falls,NY 12839 (Witness) (Address) 3)3 C t.tvs��,zt •�' —F�=si. C �172 2 (Signature of Relative or Legal Rep. and Address) Signed on this date: 9 141c 3