Waters, Leonard :;s"atSi.41;ZE
TOUN OF QUEEN4.5BU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name �� Il /f�-�J Case #
Date of Cremationj'—g-- U :2 /
Time Cremation Started
Time Cremation Completed IWI"' 191t ' t
Type of Container L` 9r' �Q& aAL/i C,2 2 E
Remarks :
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TOWN OF QUEENSBURY kj/
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:
Leonard Waters, Sr. Male
(Name) (Sex)
Box 98 Harrington Road, Wevertown, NY 12886
(Street) (City) (State) (Zip Code)
who died on the 26th day of September 19 99
at Residence Harrington Road, Wevertown, NY 12886
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Norma Hitchcock Box 65, Route 8, Bakers Mills, NY 12811
(Name) (Address)
Relationship to the deceased Mother
Name of Funeral Home Alexander Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased (RK
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
reEaaz
ed with the cremation of said remains as
dih claims or demands are or are not wholly
grfraudulent.
(Witness ) (Address)
4
( Signature of Relative or Legal Rep. and Address )
Signed on this date: �!'- 2 ZI