Bacon, Robert Sr. L 07+N OF QUEEVBU,9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Ro'bv'r+ VgCon Case#
Da to Of Cremation *�— -7 G b
Time Cremation Started
Time Cremation Completed
Type of Container C«c��otir� wl wu„ trG�e
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quakes Road, Queensbury,New York, 12WM
Cemetery Office: (518)745-4476,Crematorium:(518)745-4477
Authorization to Cremate
The undersigned requests and&Awkzes Pine View Crematorium,in aawdarnce with and subject to its Rules and Regulations to
cremate the remake oF.
Robert L Bacon M
'IF EA21 T6,L-04 RoAso4 Fads AN 1,-2P 3�
(3"")0 7/0 5/2 0 0 6 (City) (State) (Zip Cam)
who died on day of 20—
Glens Falls Hospital Glens Falls NY
at
(Place) (Address)
Name end address of nearest Wing relative or name of person au#K izkV cremation
Robert L. Bacon 27 Hudson Street
(Name) (Address)
Relatiornship to the deceased S o n
Name of FuneralMor. Carleton Funeral Home, Inc. T_
IMPORTANT:
Imposer osernt titer to Are best of my lonowledga,the dooeesed(has)or(trag no)pacemaker,deftliketor or any other betloy operated
device in his or her body. (Cute One)
I certify that I have fug power and auftwbation to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,trust any;x m r,►al possessions have either been removed or maybe deaboyed,and agree to protect,delbnd and
save harmless Pine View Crornetodurn from any and all dab, and rie- ei rim for loss ar dwm gw whidn may be made egaknet them
by oonrtacied with the aamallon of said rennakns as diedad,wAtOw suds or dww nds are or are not wholly
or
✓ \ ��) (am)
(Signature and Address of Relatib or Lagai Representative)
Signed on Ads date: /,��y
Disposition of Cremated Remains
1 hereby d, mane View Crematorium to dispose of the aea**ed rennak as follows:
Mail to
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Other em9ngements-Please spettfy: _
If prdvertzation of cremated remains Is requested,ctrecic here XX
Revision:January 1,2006
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