Locke, Robert "'MIN OF QUEEVBUPy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name �ob�s L� Case# 7 �
Date Of Cremation
Time Cremation Started
Time Cremation Completed 3C f�`7
Type of Container �qr +� ; t rr;w4ord
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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)745-4475,Crematorium: (518)745-4477
Authorization to Cremate
The ttrhdereipned requests and autfrodm Pke View Crematorkxa,In scaordBnce wwrlhh and subJecx to Its Rules and Regulations to
cremate the remakm of:
Robert Nathaniel Locke M
(Nam)
1773 West Fort Edward NY 12828-
(Street)07/22/2006 (w (�) (ZIP Code)
who died on day of 20
at Res,A�wee
(�) O
Nene and address of neseat 1 ft r*Mdva«refs of person mA Kx * cremation:
Christine Locke 111 Aviation Road, Lot
(Name) (Address)
Reletlortattip to the deoaeieed Wife
Name of Funeral Horne Carleton Funeral Home, Inc.
IMPORTANT:
I.ap esw it that to the best of my bmwiedge,the decassed(his)or(has no)psogrnM r,del b peAor or any other betttl y operated
device In his or her body. (Ckde Oro)
Ice*that I have M power and KMKv fretian to arrarge for the creeratlon or the►emakis and to dkect the dlsposidon of the
rsemeted refakts,that arty pera0rtel poRom winps he"either bean removed or maybe destroyed,and agree to protect,dehmd and
save fhernhlees pine View Crematork n from any aid aR Clelrrha and 'artartrim for ions or damages winch may be made ap hst them
by.saw t of or 'm ecied wfih the aenteft of said ramakhs as ducted,whetie►such cisisa or danumft ere or are riot wholly
groundless,false or fruxkAaht.
J ,plr+maes) (Address)
r
(Slpnatue and Address of ar l rtgeI Represehetive)
Signed on thb date:
Disposition of cremated Remains
I hereby dkect Pine View Crematorium to dispose of to cremated remakhs as folows:
Mal to
Other emovemerrta-Penn spwfy.
If pulverization of cremated renwis Is requested,clndc hero XX
Revisbrt:January 1,2006