Leary, Robert Sr. (2) TOWN OF QUEENSBURY
Pine Vieu, Cemetery and Crernntonum
27 Quoker Rond, Queensbnry, NY. 72804-5902
(518) 745-4476 (518) 745.4477
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Funeral Director:
Name of Deceased: � �Z
Case Number: C�
Date of Cremation:
Retort:
Time Cremation Started:
Time Cremation Completed:
Type of Container: VZ.+� `'4 y� (� Cl�s ,� 1
Remarks:
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TOWN OF QUEENSBURY
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 Leary 5 r, Male
(Name) (Sex)
20 Montcalm Street Glens Falls, NY 12801-
(Street) (City) (State) (Zip Code)
who died on Z 5 day of February , ;2.CCS
at Glens Falls Hospital Glens Falls,NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Mrs. Phyllis Leary 20 Montcalm Street Glens Falls,NY
(Name) (Address)
Relationship to the deceased Wife
Name of Funeral Home Carleton Funeral Home, Inc.
40
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 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,
whether such claims or demands are not wholly groundless, false or fraudulent.
68 Main Street, Hudson Falls, NY 12839
(Witness) (Address)
( ignature of Relative or Leg Rep. and Address)
Signed on this date: F 6 V,u Ct-'�J C;� 5?1 , �c:s
Carleton Funeral Home, Inc.
136 Warren St., P.O. Box 612
Glens Falls, NY 12801-
"CUSTOMER'S DESIGNATION of INTENTIONS"
Name of Deceased: Robert Leary, Sn
Cremation: Z 12911- 05 ��n� �,�eui L4 C .,.ejC
(Scheduled Date) (Location)
Manner of Disposition of Cremains:
( ) Burial at
( ) Entombment at
( ✓) Return to Family ( ) Other(Specify)
Disposition of Cremains Designated By:
(Printed)Nam
elationship to Deceased Mrs. Phyllis Leary Wife
V'Signaturc.
Address: 20 Montcalm Street
Glens Falls,NY 12801-
Telephone Number: (518)793-1785
"Cremains which shall not have been claimed within 120 Days from the date of�
Cremation may be disposed of by this time in the following manner: BURIED
AT MOSS STREET CEMETERY."
Name of Funeral Director/ or Undertaker
Doneen S.Nikas
SIGNATURE of Funeral Director/ or Undertaker
Date: 02/25/2005
11
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CREMATION:
(Actual Date) (Location of Crematory)
DISPOSITION OF CREMAINS:
Manner of Disposition:
Location: Date:
Name of Person Making Disposition:
SIGNATURE: Date: