George, Robert R .
e
rrn
OF.- UE .
PLNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director hr G �
Name 7� p(�
art 10friP C a s a 11
Date of Cremation
Time Cremation Started
Time Cremation Completed 2 �60
Type of Container
Remarks ;
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 urtdersigrW requests and authorizes Pkte View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of:
Robert Joseph George M
(Name) (Sex)
14 Blenor Avenue Hudson Falls, NY 12839 _
(Smeet) (City) (State) (Zip Code)
who died on day of 11/15/2009 20_
at Residence Kingsbury NY
(Place) (Addrmts)
Name and address of nearest living relatives or name of person authortzig cremation:
Mrs. Jessie George 14 Blenor Ave. , Hudson FallS,NY
(Name) (Address)
Relationship to the deceased Mot h e r
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge,the decessed(has) s ,deffbrtllator,battery,battery puck,power
cell,radioactive imptent or radioactive device in his or her body.(CIE )
1 cer*that 1 have full power and suthort mtlon to arrange for iha c rennOw of the remains and to direct the disposition of the
cremated remains,that any personal possessions have eiuter itearr removed or may be destroyed,and agree to protect,defend and
save hanntees Pine View Crematorium from any end all claims and demands for loss or damages~may be made against them
by Fewmaof or connected with cite cremation of said rertreins as ditWed whether such deims or daetarhds are or ere not wholly
false or lratrdulertt.
68 Main Street, Hudson Falls, NY
(Wfiness) (Address)
CXR� L 14 Blenor Ave. Hudson Falls, NY
(Signature and Address of rive or fregai Representative)
November 18, 2009
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine Vlew Crematorkrm to dispose of the cremated remains as follows:.
Mail to
Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here XX
Revision:April 19,2007