Cooper, Carol L O q' V N OF QUEE-r�45BU-Ry
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director-
am e C 0-�a0 GdU 0I=-,12, Case„
-ate 01 Cremation
Time Cremation Started_
T :me Cremation Completed
Ty pe of Container Ica
Remarks
R,�
TOWN 01: QUE=ENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbuiy. New York 12804
Phone (516) Creinalodum 745-4477 (if no answer)
Ceinelery 745-4476
AUT"I-IORIZATION I O CREMA1 E
The undersigned requests and aulhudzes Dine View t;ieinaluiiuin. in accuidance with and subject
to its Rules an gulations to cieniate the ieniains u[
(NAME) (SEX)
4 in ovm K'7�"J
(STR ET) (CI ) (STATE) (ZIP CODE)
who died on 19 day of 20-d-5—
at
(PLACE) (ADD ESS)
Name and a ress of nearest living relative or name of person authorizing cremation:
�PZIZ-
Relationship to deceased
Name of Funeral Home
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 crernalion of said remains as directed, whether
sWhior demands are or ar not wf}pllygro` dles�se or fraudulent.
1 ESS) ( DRESS)
( GNATURE OF RELATIVE OR LEGAL VEP. AND ADDRESS)
Signed on this date: •