McCormack, Robert L O T�N OF QUEEN B l_.l 1KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
_ Funeral Director
7 a T e D)0 0 GO KAX-- I C a s e y 1
`ate Of Cremation
' -- Cremation Started -'✓`
ire Cremation Completed 3 � �� �'✓�
e of Con t a i n e r C.'-yg1��2'-c - - )1Q
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Apr 21 04 03: 11p �" p. 1. 3
FROM M.B.KILMER FUNERAL HOME Fax NO. Apr. 21 2034 03:02PM P1
TOWN OF CUEENSi1l.'Rv
PINE VIEW CE?OE T ERY
8
CREMATORIUM
Quaker Ploerl. Queensoury. New York 12804
Phone(518)Crematorium 745-4477 (if no answer',
Cemetery 745-a476
AUThORIZAYItON TO CREMATE
The uneerslgr.ed requests and authorizes Pir a View Crematorium. in aezordance with and subject
',5 nS Rules and Regulations to cremate the rcma�ns of-
Robert McCormack Mr,1R
(NAME) (SEX)
6 East Notre Dame strigat Glens Falls NY 12801
(STREET) (CITY) (STATE) (ZIP .�
who died on 21 day of April 20 0 4
at 6 East Notre Dame Street Glens Falls, NY 12801
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cretnalion.
Nancy Armstrong
Relationship to deceased n ince
Name of Funarat Homo M.S. Kilmer FuneraL Home
IMPORTANT
I represent treat to the lies:of my knowledge, the deceased t:0 =rmker in his or her
body, (CIRCLE ONE)
1 Certify:mat I have the full powar and authorization to arrange for the cremation of the remains and
to direct.the disposition of the cromcted remains,thait any personal possessions have ether been
removed or may be destroyed. and Agree to protect defend and save harmless Pine View
Crematorium from any and all cloirns and demands for loss or damages which may be made
against them by reason of or cannectod with the cremation of said rem8ins as directed,whether
such claims r-qe s Bra r are n v�hmll -ndl s, false or fra4dulent.
OWN/ES.S) (AD R 5S) �� c�
Ap/1-I W a4 A4 16, ble. 3R0 4)A,V/LL'Ir
SfG URE OF',RELATIVE OR L L REP. AND ADDRESS)
Signed on tnie date;