Cooper, William . TO q+N of QUEEMs5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name �1 /�� / /� / I �Q �� Case # � 1
Date of Cremation �J — L4 — Z
Time Cremation Started .1 l •, 1� e
Time Cremation Completed ' A-A �) V ` " l
Type of Container
Remarks :
SEF- -2OO2 08:27F FROM: TO:5844462 F: 1,1
�11 TOWN OF l7UEENSBURY
�T PINE VIEW CEMETERY
a
�j CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION
The undersigned requestsa ndauthorizes RPine EView Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains /oft
(Name)
(SeK)
a IV
(Street ) (Cit ) (State) (Zip Code)
who died on day of 4y71
at�4 &1-f'gI'L aay be- r
(Place)
(Rddress)
_Name and ss of nearest living relative or name of person
aut iz ' ng c emationt
LA
(Name) A Lm�(Add ess)
Relationship to the deceased
Name of Funeral Home _S1w�,.,`�
IMPORTANT:
I repr hat to the best of my knowledge, the deceased has or
has o pac!m er 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
groundl , f 1 er, fraudulent.
1 s (Address)
( gnat ure of Relative or Legal Re 5
9 p. and Address)
Signed on this date: _