Smith, Robert TOq+N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �,�-� 4i\,O-Q, VZ
Name �`� �j ��� `� j.A.0 +—�- Case# !!/ -3
Date Of Cremation ) -
Time Cremation Started j tip.
Time Cremation Completed , -�
Type of Container CIZ 44, 04/l, (2 1:�rKL4 U�2)
Remarks ,, 1
rl 5'5 A
2cj11
1 0 t 5��r
�� ��4-
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office:518-745-4476,Crematorium:518-745-4477
"r.
Authorization to Cremate
r The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
1 RobertE. Smith Male
(Name) (Sex)
1 -3*6 Athol Rd. , Athol , NY 12810
(Street) (City) (State) (Zip Code)
who died on 10 t h day of Dec. 2p 0 5
at his home (same as above)
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Constance M. Stanczyk, 163 Armstrong Rd, West Winfield, NY 13491
(Name) (Address)
Relationship to the deceased Sister
Name of Funeral Home Alexander FH, Warrensburg , NY
IMPORTANT:
I represent that to the hest of my knowledge,the deceased W&(has no)pacemaker,defibnHator or any other battery operated
device in his or her body. (Circle One)
I certify that I have 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 C
jw9lorlium from any and all claims and demands for kiss or damages which may be made against them
by reason of or ed 0 the cremation of said remains as directed,whether such claims or demands are or are not wholly
ground sa or ulent.
Warrensburg, NY
itness) (Address)
X Same as above
(Sig tune ress of R ive or Legal Representative)
Signed on this date: 12-12-0 5
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: F H will pick up
If pulverization of cremated remains is requested,check here X
Revision:July 7,2004