Cole, Robert w
•
TOWN OF QBQ1R1Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
C_'i lvry
Funeral Director / i A /NC
Name AkRT COLE Case # 3
Date of Crematicn
Time Cremation Started 4C /7 i/V
1
Time Cremation Completed C?/3C - /A' '
Type of Container /li'9KLk)cOD -A5 7�s/I /9S.— 'f )Y
Remarks :
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TOWN OF OUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of:
Rnhprf- ,r_ r nl a
(Name) (Sex)
North Jay Road Jay, NY 12941(Street ) (City) (State) (Zip Code)
who died on 28th day of nprember 1 :8
at Residence North Jay Rd . , Jay, NY
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Mr Rn%�,�rF T Ca1,� H.B� A^X 11 North Talc- Rd , day. ?` -1 2` 41
(Name) (Address)
Relationship to the deceased Self
Name of Funeral Home M. B. Clark, Inc. 27 Saranac Avenue
Lake Placid , NY 12946
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange
for the cremation of the remains and to direct the disposition of
the cremated remains, that any personal possessions have either
been removed or may be destroyed, and agree to protect, defend
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
gro.andless, false or fraudulent.
27 Srarana Placid , NY 12946
(Witness) (Address)
�G YRC Bx 11 North Jay Rd . , Jay, NY 12941
(Signatur f Relative or Legal Rep. and Address)
Signed on this date: -nr,c '�2 , l