Round, Benjamin • TOTIAN of Qq3Qzy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director A1eXA�der
Name e °��A Case # G1
Date of Cremation LJ ZOO
Time Cremation Started /I, 1S /fi
Time Cremation Completed `'uL Qn
Type of Container Wood C,, V..ct CQ1)wF" ,p SECO,O CASE
Remarks :
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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 aidtadaPs Pine View Coasnatoduat,in aocceisnoe with and subject to Its Rules and Regulations to
cremate the r mains of
Benjamin Round Male
(Name) (Sex)
14 Burdick Ave . , Warrensburg, NY 12885
(fit) (CitY) (State) ( p Code)
who died on 31 s t day of January 2010
ac Moses Luddington Hospital ,Ticonderoga, NY
(Place) (mesa)
Name and address of nearest living relative or name of person aumorcting marathon:
/, <c44Pa 1, / 1 ,P/2 G/ 5R, /1///2 s
(Name) (Address)
Relationship to the deceased
Name ot Funeral Home Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(teas no)pacemaker.defibrillator or any other battery operated
device hi his or her body- (Circle One)
I certify that I have full power and authorlaaon to arrange for the aemadon cZ the remains and to direct the disposition of the
cremated remains,that arg f personal possessions have ewer been renewed or may bedeslroyed and agree to protect.defend and
save harness Pate View Cremetaten from any and all clabns andriames ds fir toes or Manages which may be made against them
by reason of or•• •: •with Ste of said reua na as erected whether such claims or der acids am or menotwholly
groom,.�:,._ : or
7m
(Address)
i\C) 414/170/t/ 151//// //Y(Siignature and Address of Relative or Legal�)
Signed on this gate: February 1 , 2010
Disposition of cremateo Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mall to
Other arrangements-please specify: FH will pick up
If pulverization of cremated remains is requested,check here_ X
Revision:40.7-2004
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