Roberts, Dana Yr
OF
PLNE YI EW CEMETERY AND CREMATORIUM
QUAKER ROAD, Q(jEENSB Ry, NEW YORK 12504
(518) 745.4476 (518) 745'•4.477
Funeral Director '
arlrfa�,
Name
7��a 11°i�f15
Case#
Crema t i.on , i 30
Cremation Started
^e Cremation Completed
� r ?e of Container ' 6
ti
Remarks
�Iv�
Town of Queensbury
Pine Yew Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477 '
Authorization to Cremate
The utclersigrted requests and auk hors PMte View Cnemetariurn.In aawrftwe with and twbjed to Its Rules and Reguletb m to
crenmte the remains of
Dana Marie Roberts F
(Name) ( )
8.27 Dewey's Whitehall NY 12887-
(Shvet) 0412612007 (City) (Site) (Zip Code)
V"dled&lens Falls Hospital fyWens Falls NY 20_
at
O O
Name and address d neereet living rewom or name of parse~outdxwtdv wgp.m ut:
(Name)T±na Turner (Address)
Raletionehip to to decsseed Mot her
Nwm ofFttrteralFlorrre Carleton Funeral Home, Inc.
IMPORTANT:
I repreeertt that loft beet of my knowledge,the dooeatiad(tms)or(has no)pacemaker,d&%riAator,battery,bettery pack,power
cell,radioecdve implant or nKftecgve device In his or her body.(CMde One)
I oertily stet I hwm ftA power and wAhmiratlon to wmnge for ttta cremation of the repo is and to dkect the dispoealan of the
cremated smalls,that any personal posesesions have aid been removed or may be destroyed,and agree to pnAact.,defend and
save hartWeea Pkne View Cremobritim from any and all claims and demands for loos ar derrtsDss which may be made ag*id#hem
by meson d or connec ied wk h dte crenmtim of said rornaMrs as d MCMd.wltedW such deinrs ar demands are not wholly
false or fiaudttle�
( )
(Signatmae and Address of R
elative or Legal Representative)
Signed on this date: 0 7
7
Disposition of Cremated RemaMts
I hereby direct PMte View Cremalorictrn to dispose of the oemated remalm as bNows:.
Mail b
Outer arren pNnw is-Please specify:
If pulverization of Cremated remains is requeWW,check here XX
Revtsktrt:April 18,2007