Morford, Coleman T • • TOWN N OF QTfEAiB (..1
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 11 3 aA'K
Name (oie Morford Case # 11
Date of Cremation (14,vicIfi 12I 70/6
Time Cremation Started 7 v c Ph
Time Cremation Completed IU . 2s pi
Type of Container v
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Remarks :
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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 Regulations to
cremate the remains of:
COLEMAN T. MORFORD MALE
(Name) (Sex)
291 MILL POND DRIVE, LAKE PLACID, NY 12946
(Street) (City) (State) (Zip Code)
who died on 5th day of JANUARY 3*.2 2010
at ADRK MEDICAL CENTER , LAKE PT.ACTTS; , NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
RICKEY MORFORD 292 MILL POND DRIVE, LAKE PLACID, NY
(Name) (Address)
Relationship to the deceased FATHER
Name of Funeral Home M. B. CLARK, INC. LAKE PLACID, NY
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that I have 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
groundless,false or fraudulent.
1 tea-,I( 231 ARANAC AVE. . _T.AKF. PLACTD, NY 12946
acAg(Witness) (Address)
292 MILL POND DRIVE, LAKE PLACID, NY
nafGre and of Relative or Legal Representative)
•
Signed on this date: J A N. 06, 2010
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mallto M. B. CLARK, INC.
2310 SARANAC AVE. , LAKE PLACID, NY 12046
Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here XX
Revision:January 1,2009