Romer, Shirley OF
QUEE9 v B U�y
PINE VIER' CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW PORK 12804
(518) 745-4476 (518) 745-4477
II Funeral Director
Name �iP1( -"r
Case# (�
Date Of Cremation
Time Cremation Started
1 10
Time Cremation Completed (U•,'Jv
Type of Container
Remarks CA
M ; 2G
NO v67
5 � s'O14
t0 Al7
C'oaC a:3b
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12MM
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477 '
Audxmization to Cremate
The utdtxslgrted regereals and autltorlaes Pate View CMnM&rium,in a000rdenoe with and subject to Its Rules and Regulations to
gamete the remain of:
Shirley A. Romer F
(Name) (Sex)
2.6 A Platt Glens Falls NY 12801-
(Shim) (CRY) Owe) (ZJp Cam)
who died on day d 12/31/2 0 0 7 20_
at Residence Glens Falls NY
( ) ( )
Name and eddreae d on no ii ng ref Wva or name of person aunt xb*V cremation:
Carolyn Smith ��, �en eccer •�J�, �- ei , �L�J �'/x/
(Nam) — (mew) T r—
RaWJqneh1ptoft deceased Sister
Nemed Funeral lim. Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the beet of my ,the (=) 0 IS rro ,deAlb 4olor,ba y,betkxY lam,power
CA radkxoclive intptent or ra*oectire device in his or her body.( )
I c w*that I have full power end eudwri¢etlon to arrertge for the crrenwkin of the remalns and to direct the depoeition of the
creumW rameats,that any peraonW poeaessions have either beer[removed or maybe destroyed,artd agree to prtriect,defend and
sews hernifto Pbm View Crattomium from arty and an cisittte and derrtertds for im or damages which maybe[trade egalnet dtam
by reeaon of or omriet2ed whit dttr cremation of said[ante as d maed,whedter atxit clal s or darrke do are or are not wholly
grourtlaw false or fiattdulW.
68 Main Street, Hudson Falls, NY
(Address)
end Address of Relative or Legal Representative)
Signed on this date: `J Q r' a2 d'00 0
Disposition of Cremated Remalne
I hereby direct Pine View Cremstorlum to dlepaes of the cremetad remekts as follows:.
Mail to
OVw arrangernenta-Please spedry:
If pulver¢ation of cremated remairo is requested,dtadc here XX
Revision:April 18,2007