Cooper, Harold 7
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PIN 'S'YE�' C UEE`� `��sB
.. . EM�TERY q
' R ROAD, Q(jj NS CREMA.r
(S18) 745.4476 ��Y' NEW YORK R 8pgM
(S18) 745.4.477
\'ame Jar . " Funeral Director o_
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Dare Of Cremation Case# 5t1L
Time ✓� cm
Cremation �e f 7 SS
Started
Time Crematlo� /; U �'
T Completed 3 3C
Ype Of Container
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Remarks c,rr
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulation
cremate the remains of
s to
(Name)
(Sex)
(Street_)— — U +
whoLO
died��t
T (C+ty) ! (State) (Zip Code)
---__ day of04)
(C�v 2Q
at_ (Place) �� `�^ L�aJS
Name a address of nearest living relative or name
l/. ice_) pers°n aut rrzing cremation:
�, - S4ti t
Name) ( ddre ) � L /��7 Sit1Zl�
Relationship to the deceased' S
Name of Funeral Home 1 , z�� _/7!_
IMPORTANT:
I represent that to the best of my knowledge,
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device in his or her body. (Circle One) the deceased(has)or(!(as no) cemaker,defibrillator or any other batter
y operated
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the di
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 Toss or dams to proon of the
by tea for oonneded with the cremation of said remains as directed,whether such claims or demands are or are not wholly
ges which may be made against them
grown or fraud t. /
(Witn
C� (Address)
(Signature and ress of Relative or Legal Representative)
Signed on this date: Z
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
LUR to ,
Other arrangetrtents-Please spe .
If pulver¢abon of cremated femamm requested,check here
Revision:JarmM 1,2006