Rice, Robert TOWN OF QUEENSBURY
Pine View Cemetery and Cremnlortttm
21 Qunker Rond, Queensbury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
http //www.queensbury net
Funeral Director:
Name of Deceased: /►� (Z- C' El
Case Number: D
Date of Cremation: '3 — �f 2 G G �J
Retort: C-M9tW'�--o1'1-�
Time Cremation Started:
Time Cremation Completed: 3 D
Type of Container: Q�\A 0- \3y AA L4
Remarks:
is-
0 -3
" Ho tit e of NntitrnI Benuty ... A Goo (1 PInie to Ltue "
SENT BY: ; 802 492 3028; MAR-8-05 10:44AM; PAGE 1 /1
03/03/2005 03:36 5186422322 RQBERT M KING FH 01
I FAu�
TOWN OF QUEENSIBURY
PINE VIEW CEMETERY
8
CREMATORIUM
Quaker Road,Queensbury. New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and autnorzes Pine View Crematorium, ,r accordan,e with and subject
to its Rules and Regulations to cremate the remains of
+Ma�rr�aie Bentley Rice Ferale
(NAME) (SEX)
8534 Cold River Rd. Shrewsbury, VT 05738
(STREET) (CITY) (STATE) (ZIP CODE)
who died on _7 day of March
at Glene !FalIs Hosgi-tal , 100-102 Park St. Glens Falls, NY 12501
(PLACEi (ADDRESS)
Name and a0dress of nearest living relative or name of person authorizing cremation:
David! Rice.853L Cold River R. Sh P3jnhuj:X.V ' 05718 _
I
Relationship4o deceased on .F
Name of Furnera! Home Robert M. Kinz Funeral Hone
I MPORTA Nt
I represent that to the best of my knowledge, the deceased WU or has no pacemaker in his or her
body (CIRaLE ONE)
I Certify that I have the full power and authorization io arrange for the cremation of the remains and
to direct the disposition of the cremated rerrains, that any personal possessions have either been
removed or may be destroyed,and agree to protect, defend and save harmless Pine View
Crematorium`rom 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 or are not wholly groundless, false or fraudulent,
(Wt NES (AD RESS) � S�38' • `
(SI NATURE OF RELATIVE p EGAL REP. AND ADDRESS)
Signed on t�lis date: O 2c�c r` '.