Morrisey, William 70 WN OF Q �� 5B U99y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director -&A2al—iju
Name / Ss Case #
Date of Cremat i cn , d
Time Cremation Started
Time Cremation Completed
Type of Container
Remarks :
r Iyt a
i
i
TOWN OF DUEENSBURY
PINE VIEW CEMETERY
b
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,
accordance with and subject to, its Rules and Regulations to
cremate the remains of :
William C. Morrissey Male
(Name) __. (Sex)
P.O. Box 1, Pottersville, N.Y.12860
(Street ) (City) (State) (Zip Code )
who died on 22 Ad• day of May 1999
at Glens Falls Hospital, 012 Park St. , Glens Falls, N.Y. 12861
(Place) (Address)
Name and address of nearest living relative or name of persz,n
authorizing cremation :
Willian C. Morrissey II, P.O. Box 1, Pottersville, N.Y. 12860
(Name) (Address)
Relationship to the deceased Son
Nave of Funeral Home Alexander Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceasedX]00�j=
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 t'he remains and to direct the disposition of
the cremated remains, that any personal - possessions have eitner
been removed or may be destroyed, and agree to protect , oefemc
and save harmless Pine View Crematorium from any and all c : a : ms
and demands for loss or damages which may be made against them
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wno : : ,
groundless, false or fraudulent.
&1oleize ek—r-
5048 State Rte.9, Chestertown, N.Y. 12817
(Witness ) (Address)
(Signature of Rel tive or Legal Rep. and Address)
Signed on this date : May 23, 1999