Cubbins, Robert OF QUEEN,,,5ouj�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4-477
Funeral Director �CKfi
a" elk(313F_1? C,L) 1sC4 4---. Case;:
-ate Of Cremation c� . Z _ ZopA4
Cremation Started
Cremation Completed M_
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441
Apr 08 04 10: 02a Sue Williams 703-742-5997 p. 6
REGANEDENNY 01346
04/08/2004 09:25 516-792-1287 j
TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM
Quaker Road,Queensbury.New York, 12804
phone(515)Crematorium 745-4477 of no answer Cemetery 7454476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in Accordance with and subject to its
Rules and Regulations to Cram-1te the remains of.
(Name) (Sex)
4 a
(Street) ` (city) (Rate) (zip)
who died on day of 20 Q!1 —
Na
(Ply) (Address)
Name and address of nearest relative or name of person authorizing cremation:
(N e) (Address)
Relationship to the deceased_ n r�
Name of Funeral Horne {
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or 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 dispos tion of the cremated remains, that any personal possessions have either been removed
or may be destroyed,and agree to pro".defend and save harmless Pine.View Crematorium from any
and all claims and demands for toss or damages wriich may be made against thorn by reason of or
connected with the cremation or said remains as directed,whether such claims or demands are or are not
wholly groundlese,false or fraudulent.
(with) 1 dress)
{Sirl-y
f R at r Legal R .and Address))
Signed on this date;._ .4 5r