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Kopchuk, Edward rl-nq+N OF QUEEN,5BU9�Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY. NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director �� ,C Name ��)&E ��z:( Case # 91.L Date of Crematicn Time Cremation Started /� f '4IbA Time Cremation Completed /c�- r 16 Lo Type of Container �yt/ Remarks : �d � , i 1 //%a 4 'ov') �• ►o© i TOWN OF OUEENSDURY PINE VIEW CEMETERY CREMATORIUM i Quaker Road, Queensbury, New York 12804 phone (518) Crematorium 745-4477 or if no answer Cemetery 74n-4476 AUTHORIZATION TO CREMATE The undersigned requests and authorizes Pine View Crematorium, in accardance with and subject to its Rules and Regulations to Cremate the remains of, Ka chak Male (Name) (Sex) Nelson Ave . _Saratoga Springs N ( (Street) (City) (State) (Zip Code) who died on 5 day of June 19 99 at Brentwood M Sarato r (Place) (Address) Name and address of nearest living relative or name of person kr authorizing cremation: 'Zid/V .u:t•/ik tilt't �'d 1 ,�f 5.7 A f►l �o �]LlA/d (Ne►at) (Address) Relationship to the deceased H A,L.JACOBSEN FUNERAL HOME INC. 11746 Name of Funeral Hamm INGTONSTA. NY I MiMRTANT 1 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 1 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 harwtless Pine View Crematorium from be maany y aand al ltclaims by and demands for loss or damages which may reason of or connected with the cremation of said remains as directed, whether such claims or demands are or are not wholly groundless, false or fraudulent. ALJACOSSlN FUNERAL HOME WC. 1i0 NY AVE FG'rON STA.,NY 11746 iu•y (Witness) (Address) (Signature of Re Live or Legal Rep. and Address) signed on this date :