Roblee, Clara M L O`!4 OF Q5v $T1R9
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Aleyq.litr
Name � c Dhlet Case # 57
Date of Cremation Q b Z00
Time Cremation Started . Uc
Time Cremation Completed (0 10 R M
Type of Container cinttul'ul C OR " r S
� � f� stCsc
Remarks :
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Town of Queensbury
Pine View Cemetery and Crematonurn
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office:518-745-4476,Crematorium_518-745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Cistoriwu,in accordance with and subject to its Rules and Regulations to
cremate the remains at:
Clara M. Roblee Female
(Name) (Sex)
(Street) (Cay) - (sue) R p Code)
who died on 31 clay of Jan. zu 10
at The Stanton NH, 0ueensbury, NY
(Place) O
Name and address of nearest living relative or name of person atahortang ahenmeon:
(Name) (Address)
Relationship to the deceased d a u.
Name of Funeral Home Al exandpr-baker FH, Warrensburg, NY
IMPORTANT:
I represent that to the best of my knowledge,the deceased( no)pacemaker,delithillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have tuft power and authorizalion to arrange for the cremation of the rem and to direct the disposition of the
cremated remains. !possessions have miller been removed or may bedeeavyed.and wale to protect.defend and
save harm ' e View 'urn horn seri and aft claims and demands for Loss or damages which may be made against them
by r or connected tie madon of sold rernalne as articled,Whether such claims or dads ate or am not wtofty
false or
Warrensburg, NY
(Witness) (Address)
X
(Signature and Address of Relative or legs!Representative)
Signed on this sate: 2-1-10
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mall to
Other arrangements-Please speaty: FH w i l l p i r k up
If pulverization of cremated remains is requested,check here X
Revision:Jygr-7-39b, 4
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