Dobler, Elizabeth rrn7+N OF QUEEN5BU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director r(afi�:�
Name E (,2"� ;t� I/4���f Case#
Date Of Cremation
Time Cremation Started 4 G, Ail
Time Cremation Completed 11 ; R.n5 A6
Type of Container 00 d 65(6 Crq,,,4Lxd )3; cmSF_
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quakes Road, Queensbury,New York, 12W
Cemetery Office:(518)745-4476,Cref latorium:(518)745- 477
Authorization to Cremate
The undersigned requems and auMortres Plne view Crematorium,in ecoordence with and subject to its Rules and Reputations to
cremate the remains of•.
Elizabeth Jane (Burnie) Dobler F
Fort Hudson Fort Edward NY 12828
(Street)0 7/12/2 0 0 6 (CRY) (State)
(zip Code)
who died on day of 20—
Glens Falls Hospital Glens Falls NY
at
( ) (Add)
Name and address of nearest WAV relative or nmme of person auborb*V cremation:
Mr. Bernard Dobler 29 LaCrosse Street
(Name) (Address)
Relaft of ip to the deceased Husband
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
1 rapreaerrt that to the best of my lamwledge,the deceased(has)or(has no)ppoernalter,deftillator or any other battery operated
device in his or her body. (Ckdo One)
I w*that t have full power and authorization to arrange for the cremation of the remains and to direct the dlsposibon 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 Cremetariun from any and all daims and demands for foes or damages wHch may be made against them
by mesm of or connected with the cremation of sell directed,whether such deans or demands are or are not wholly
goukiless, orfreudulent.
(wibees) � (am) /
. t
(Signature and Address of Relative or Legal Representative)
Signed on dais dote: a,10
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as folbws:
Mail to
Otfrer arnengements-Pbeee�tY: _
if pulveraation of cremated remains Is requested,clnedc here XX
Revision:January 1,2006