Jabaut, Robert LO YVN OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /1/► �A3(� •�
Name ✓�7 �����--1 f K`/� 1,`` Case# o
Date Of Cremation -Z�-i
Time Cremation Started
Time Cremation Completed
Type of Container
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Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The urKdersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
Ro&e,t 70 /V)
ref
(Name) (Sex)
(Street) (City) (State) (Zip Code)
who died on cday of 2000
at y( tvac-A-w `'� 0 '1 l_ko l
(Place) (Address)
Name and address of nearest living relative or name of person aunxxt ing cremation:
(Name) (Address)
Relationship to the deceased
Name of Funeral Home 11� 1 I✓ 1 ^�r'�
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no pacemaker,defibrillator or any other battery operated
device in his or her body. (Ckde One)
1 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 Crematorium from any and all claims and demands for loss or damages which may be made against them j
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.
(Wig) _ ( )
(Sign re and Address of Relative or Legal Representative) j
Signed on this date.C S U
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Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
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Other arrangements-Please specify:
If puNerrmtion of cremated remains is requested,check here j
Revision:January 1,2006
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