Robichaud, Stanley Funeral Director:
Name of Deceased: S+a R v 6 I c E1 qvA
Case Number: a Li1
Date of Cremation:
Retort: CM w��
Time Cremation Started: l = u 0 A .M
Time Cremation Completed: /�
InI _M
Type of Container: C��c� Loc►rd�
Remarks:
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CRERi1TORIUK
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AU2NORISATIOR TO CRZMM
The undersigned requests and authorizes Pine View Crematorium in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
54-o'?ICU -3'
(Name) (SOX)
7 au Qe-5 r =� . 28�
(Street) (city) (State) (ZJp Code)
who died on day of � �
at
(place) (A ess)
Name and address of nearest living relative or name of pen
authorizing cremation:
r e
(Name) e s) 1
Relationship to the deceased
Name of Funeral Home
INMTANT:
I that to the best of my knowledge, the deceased has or
as no pacemaker .n his or her body. (Circle One)
I certify that I have the full power � directrt�hetdisposition of
for the cremation of the ruins tonal possessions have either
the cremated remains, that any Pere
been removed or may be destroyed, and- agree to Protectr defend and
save harmless Pine Viet Crematorium fxvn any and all claims and
demands for loss or damages which may be made against them by ,,
reason of
wohetherconnected
s ch claims or cremation
demands are or are notes
direct wholly .
,
groundless, false r raudulent.
t ess) (A ess
(Ss.gn ture o Re ative or Legal Rep.
address)
LSigned on this date:
J