McClard, Robert r
PWE YIEW C .J QUET:,g\�5rBur?,
EMFTERY AND
f l'UX,CEA ROAD CREMATORIUM
QUEI.'NSBT'RY, NEW YORK 17804
(518) 745.4476 (518) 745•4-477
Funeral Director /
Cremation
Te Cremation Started
T ' me Cremation Completed
' r ?e of Container
lu
C, 1 s �
PM
Z 4 G
�06L 3 iC h
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 undersigned requests and authorises Pkte View Grernetariunt,in accordance with one subject to its Rules and Regulations to
cremate the remains of:
Robert Ira McClard M
(Name) (SOX)
Fort Hudson NursiRgXtCEri cErd NY 12828-
(SUW) (City) (State) (Zip Code)
who died on day of 02/22/2009 20_
at FORT HUDSON HEALTH CARE FACFort Edward NY
(place) (Address)
Name and address of ndarest living reledvr3 or name of person audwrizing aeration:
Becky Beatty 4 Lydia Apt. B, South Glens Falls,NY
(Name) (Address)
Reletion9nip to the deceased
Step Daughter
Carleton Funeral Home, Inc.
Name of Fameral Horne
IMPORTANT:
I reprewo that to the best of my taaowladg%the dooeesed(has)or(has no)pacemaker,debbrr7ator,battery,battery pack,power
ceN,radioactive implant or radioactive device in his or her body.(Ckde One)
I certify that I tan Taal power and auffwdzatlma b arrange for the cremation of the remakae and to direct the depoet Ion of the
cremated remakes,that any personal poe®essiom have eN ar boar nwKwed or may be de sb yed,and agree to pn*wt defend and
save harmless Plne View Crernelarium from any and act claims and dernands for bas or damages which may be made against them
by reason of or contacted with Ole cremation of acid remains as dbecfed.whether such claktrs or demands are or are not wholly
�false or
_ _ /7 8 Main Street, Hudson Falls, NY
(Witness) (sm)
�- 4 Lydia Apt. B, South Glens Falls, NY
(Signature Address of tine a legal Representative)
n�Sgraed on this dace: ✓
Disposition of Cremated Remains
I hereby dkect Pine View C rematorkrm to dispose of the cremated remakes as follows:.
Mau to
Other arrangements-Please aPedfy:
tf ptitl .etion of cremated dery m s is requested,check here XX
Revi xr April 18,2007