Cooper, Janet C •
•
TOWN OF QUEENSBURY
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:
Janet C. Cooper Female
(Name) (Sex)
Lake Road, Box 415 Ticonderoga New York 12883
(Street ) (City) (State) (Zip Code)
who died on 7th day of November 19 96
at Moses Ludington Hospital, Wicker St. , Ticonderoga, New York 12883
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Roland H. Cooper, Lake Road, Box 415, Ticonderoga. New York 12883
(Name) (Address)
Relationship to the deceased husband
Name of Funeral Home Wilcox & Regan funeral home
IMPORTANT:
I rep esent that to the best of my knowledge, the deceased has or
has 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 cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
(Mut- a 4-1,01
(Witness) (Address)
0 h
(Signature of R lative or Legal Rep. and Address)
Signed on this date : November 7, 1996