Decker, Robert A TOT1AN OFQUEE.9Q'BUWy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director / /r
Name Er* �'c
d' Case #_i3L___
Date of Cremation fr1 r •� �1 ZOO
Time Cremation Started aU
Time Cremation Completed
Type of Container (A!< �Di1r 6 14'
remarks :
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41 13.0
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own of Queensbury
Ana View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
et mtery Office:(518)745-4478,Crematorium:(518)745-4477 •
Authorization to Cremate
The undersigned requite:t endauthorizes Pine View Cremation.in accordance with and subject to its Rules and Regulations to
cremate the remabta ck
Robert A. Decker male
(Name) (Sex)
10 Ashe Drive Warrensburg, NY 12885
(Street) - (Cty) (State) (Zip Code)
who died on /if / day of n t.c/I 20
at WEST,l .V1' N_ Xi QiCoi5. way eu.y_
O (Address)
Name and address of nearest ling relative or name of person authorizing aemation:
David L. Decker 23 3rd AvP Warrensburg, NY
(N ) (Address)
Relationship to the deceased S O n
Name of Funeral Home Alexander-Baker Funeral Home
IMPORTANT:
I represent that to thebest rimy imow edge,the deceased:(bas)er(has no)pacemaker.deftrllatar,battery,battery peck,power
cell,racloactive implant or tadtoective device in his or her body.(Circle One)
I certify that I have full power end authorization to arrange for the cremation of the remains ins and to elect the disposition of the
cremated q aRortat pveseesians have either been mewed ar aim be destroyed,and agree to protect.defend and
save , 1 Ctetualorim from any and a0 claims and demands for kris or damages whichmade against them
by •• . .`. the cremation of said remains as deeded,whether such claims or demands are or not wholly
iiii
(Witness) -, SPw S (Address)
t kie L * ) Ya 10 Apia PA f lApre f9ue,ti`1
(Sig ature and Address of Relative or egal Repmeentative)
Signed on this date: 3 Z t& — 0 g— — Pa AI(
tJisposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:.
Mail to
Other arrangements-Please ase specify:
If pulverization of cremated remains is requested,check mere X
Revision:April 18,2007