Hart, Robert rrn
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PIKE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURy, NEW yORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name
r Case a LL��
Date of Cremation Ililllljllil261,
Time Cremation Started
woo (�
Time Cremation Completed
'x
Type of Container
Remarks :
MAIN ICE Iy A+1 okji�- to 110 Act
1 *IU
Town of Queensbury
Pine View Cemetery and Crematoitum
21 Quaker Road,Queensbury, New York, 12&9
Cemetery Offlce: (518)745-4476, Crematorium: (518)745-4477
Au#Kxbmdon to Cremate
The terdsMV'Gd mqus is and autlnodm Plne View Cie nMdum,In aaoorderm with and subject to its Rules and Regulations to
creyte the remains of:
Robert E Hart M
(Name) (Sep()
17 Moreau Drive South Glens Falls NY 12803-
(811'set) (CRY) (State) (7Jp Code)
who died on the 9th day November 2009
at The Pines Glens Falls NY
(Place) ( )
Nerve and address d rrrlerest IM%give or name of prism euthorbft aerrraaion:
Linda Hart 17 Moreau Drive
(Name) (Address)
Reiatiorwhip to the deceased W i f e
Name ofFunerelliorrre Carleton Funeral Home, Inc.
IMPORTANT:
f represent that to the boat of my tatvwledge,the de (has no) ,deftdiator,battery,bar per,Power
cW,radioK*m h.on or redamxire devise in his ocher ttodY-
I ow*that i hum*A power and audwrizedon to arrange for the cxems*n of the renwin s end to dherX the dispoellon ar the
crenrattrd remains,that any personal possessions here oMm been removed or maybe destroyed,end agree to protect,defend and
seve harmwe Pine View CrametorIum from arty and aN claims and demands for tees or damages wfWn maybe rnado agiew aot twn
by reason of or caxnecM wNh the cremation of add remains es directed,whedw audt dents or demands are or arc;not wholly
or
68 Main Street, Hudson Falls, NY
(Witness) (Address)
17 Moreau Drive,, South Glens Falls
—' (Signature and Address of Rekd ve or Lwai Representethre)
Signed an this date: � r
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as fdlows:.
Md d
Other anvVemerrta-Pissee Spew--
If putverbow of owns d remains is requested,dv&here XX
Revision:April 18,2007