Latham, Robert OF QUEENB 21
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745'-4-477
1
Funeral Director
Fame
Case#
Dace Of Cremation
Time Cremation Started 3G
Time Cremation Completed
TYPe of Container CArtI�jut"J
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 undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the rernaire of:
Robert Farrell Latham M
( )
The Landing, Glens Falls, NY
(Sir") 12/24/2006 (CIW ( ) (Zip Code)
an day of 20�
dens Fails ospi aG ens Falls
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at
(Place) (Adder)
Name and addroas of neere+at Wing relative or name of person auVxxQ V cranation:
Mrs. Jayne Pratt 242 Old Town Farm Road ivLf�/Gfrr +�'�• !
(Name) (Address)
Relationsh toip the deceased Daughter
Name ofFunwWHome Carleton Funeral Home, Inc. T`
IMPORTANT:
t represent"Wd 10 the best of my iunaiwledge,the deceased(has)or(has no)pacernaker,defibrf oor or any other battery operated
device in his or her body- (C:de one)
I Certify that I have full power and m*Kwbztion to arrange for the crawakm of the remains and to direct the disposition of the
cremated remains,that any personal poseessrons have either been removed or may be destroyed,and agree to protect,defend and
am%harmless Pine View Crematorium from any and ail clakns and demands for loss at damages which may be made apahist them
by reason of or connected with ow cremallon of said remains;as directed,whalher such claims or danends are or are not wtwMy
.tales or fraudulent.
)
l� �� t 24 2 %��,w,far.r.w/� / / vr.
( and Address of or Legal Repres re) u f !
signed on this data.
Disposition of Cremated Remains
I hereby direct Pine view Cremmodu n to dispose of the uerneted remains as follows:
Man to
Other arrangements-Pleeae specify:
if puhrerizalion of cremated remains Is requested,check here XX
Revision:January 1,2006