Robinson, Harry OF
PINEQUEEN,5TUjr�
VIEYV CEMETERY AND CR
Qt1�KER ROAD, EMATORIUM
QUEENSBURy, NEW YORK 128o4
(5 l 8) 745-4476 (518) 745'-4477
Funeral Director
am e lctCr -JIL"(1
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Date Of Cremation
Time Cremation Started 11 ��
Time Cremation Completed
Type of Container
Remarks
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L OIJ 3 v
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, QueensWry,New York, 12804
Cemetery office-(518)745-4476,Crematorium:(518)745.4477
Authorization to Cremate
The undersUned requests and arr<fMwn Pine View CfBMWOrLu n,n accordance with and eu*d to its Rules and Regulations to
cremate the remains at
Harry LeRoy Robinson M
17 Delaware Ave. Hudson Falls NY 12839
(Street) (City) (State) (ZIP Cam)
who died an 31st dayof January 2007
at Residence Hudson Falls
(fie) (Address)
Name snd address of nearest WkV relative or name of person augwrhang aem@bmr:
Mrs. Sharon Robinson 17 Delaware Ave.
(blame) (/drm)
Relatiorrship to Im deoessed Wife
Nam ofFuneratHon Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my wxwAedge,the deceased(has) nraloar,det b MaW or any other bet y opergted
device in hit or her body. (Circle One)
1 certify fuel I have rut power and authorization tp arrange for the aemetion of Me remains and to direct the disposition of the
cremated remains,itret any Persdrsi Posteseforrs he"either been removed or may be desboyad,and agree to protect,defend and
save hrrs OOM Pine View Ctetrretmtum from any and aq clskrrs and demands for Loss or damages wtririr may be,,fade apeiret them
by reason of or connected with ttre QBmalion of said remains as directed,wheMer such chins or demerf(ts are or are not wh*
(vYMeasl (Add am)
(Sip*Wn?and Address Of Relative or LOW Representative)
Signed on this date:
Dispossiiiion of Cremated Remains
I hereby direct Pine View Crwnetodum to dispose of the cremated rameft as tlbws:
Man to
Other arrangements-PWaae apedy:
If P*eraakm of cremated remains Is requested,dwx*here XX
Revision:January 1,2006
f
OF QUEE9,�50uTPWE YIE'FY CE
CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEPNSBURY, NEW YORK 17804
(518) 745.4476 (518) 745'-4477
Name
Funeral Director
.4lexAA&
1
err QCAIA c.'. C a s e �(1
:aye Of Crematl.on M
)00-7
Te Cremation Started
me Crematlon Completed
. 1n 6h
Pe of Container
hrC GtOir( .G� I S L
---------------
Remarks
a�ao
foci y,ao !�M
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 ou@horimes Pine View Crerne riurn,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
Harry Robinson Male
(Shaw) (CIh+) / (fie) (Zip Code)
whodtdon 11th cleyof May 2p07
at Glens Falls Hospital , Glens Falls , NY
(fie) ( )
Name and address of nearest living relative or name of person authorizing cremation:
Stacy Dobbs Glens Falls NY
(Name) (Address)
Relationship to the decreased Daughter
Nam..fFunerWHomeAlexander-Baker Funeral Home, Warrensburg, NY
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has np maker,deflb Wor,bettery,battery pack,power
cell,radioactive Implant or radioactive device In his or her body.( )
I comity that I have full power and authorization to orange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either beery removed or may be destroyed,and agree to protect,defend and
save Pine stortum from any and all dairns and demands for loss or damages which may be made against them
by or conrte wit of said remains as directed,whether such claims or demands are or are not wholly
or
Glens Falls
(Wi (Address)
�— Warrensburg
(Signature and Address of Relative or Legal Representable)
Signed on this date: 0 5/12/2 0 0 7
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:.
Mail to
other arrangements-Please spedfy: g t, t o Alexander Funeral H om
If pulverization of cremated remains is requested,check here
Revision:April 18,2007
w�
Policies, Rules and Regulations
1. Pine View Crematorium is located on the grounds of Pine View Cemetery.The
Crematorium operates Monday through Friday from 7:OOam to 3:30pm. Prior telephone
arrangements for the acceptance of remains are necessary. Prearrangements are
necessary for overtime or Saturday cremations.
2. A 'Authorization to Cremate'form signed by the nearest next of kin is necessary stating
that they do have the power and authority 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 Cemetery and Crematorium from any and all claims and demands
for loss of damages which may be made against them by reason of or connected with
the cremation of said remains and/or disposition of said remains as directed,whether
such claims are,or are not wholly groundless,false or fraudulent This authorisation in
addition to a regular burial permit must accompany the remains.
3. All remains must be in a casket or suitable aftenu fe container. Caskets and containers
must be of a combustible material.No styrofoam or plastic containers will be accepted.
4. Any Cardiac pacemakers,defibrillators.battery,battery pack,power cell, radioactive
implant or radioactive device must be removed from the body before any remains will be
accepted.
5. Cremations will be completed within three working days(72 hours)of receipt of the
Burial Transmit Permit and Authorization to Cremate Form.The cremated remains will
be mailed via Registered U.S. Mail within three days of cremation to the funeral home
handling the service unless other arrangements are made.'There will be a$30.00 Charge
for this service.
6. Cremation, Administration Costs and Recording Fees:
Adult $3330.00
Children (age 13 months to 12 years) $180.00
Infants (stillborn to 12 months) $130.00
Overtime Cremations(Weekdays) $480.00
Saturday Cremations $480.00