Carroll, Robert Jr. T07/�� OF QUEE9\�5oUT
WE 'YIE'Gy CEMETERY AND CRE
QUAKE '
R ROAD, QUEENSBURy, MATORIUM
(518) 745-4476 NEW YORK 12804
(518) 745-4-477
Funeral Director
.Fame � L.'/' � � r
Case#. �
Date Of Cremation U
Time Cremation Started
Tame Cremation Completed
Type of Container (,Jap Oa4
Remarks ------------
r �aP,
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 authalaes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
Knbcft t Ow fU I l .Jr. "Od —
(Name) (Sex)
I`-I l-ogan Ave. . G lens Fal(S A)"'kJ-- I2 M/
( t) (city) (stye) (Zip Code)
n 1
who died on 10 day of. I'I CL&-0.-1 20-0Y
at InkaA Q 1"Ave LA elft;Lc An cr . 1 IyCt G�ASt]t1,C�rany�IIQ,N`( 1283"Z
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
La t -a C�t,,,n-o 1y Lwnn Nc'....GlansFcd s, k) i2Xoi
(Name) J ( )
Relationship to the deceased tN i
Vf—
Name of Funeral Home Oa&j r)aAa ps urle rink,I A--Lrnfz—
IMPORTANT:
I represent that to the best of my knowledge,Ute deed(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Cirde One)
I certify that i have full power and an0wrization to orange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessiorts have either been removed or may be destroyed,and agree to protect,defend and
save harntgess Pine Viers Crerratorl utr from any and al clawts and denta nds for loss or damages wfidt maybe made against them
by reason of or connected with fhe cremation of sold reampts as directed,v*Ag r such claims a demands are or ate not wholly
ground ,false or fraudulent.
i.Aa�
(Witness) (Address)
A^— Qt161A.0A
(Signature and Address of Relative or Legal Representative)
Signed on this date: s 13 I Og
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007