LaRocque, Raoul own v ueeni "T.
rtr1E viEW CEMCTERY and CREMATORIUM
QUAKER ROAD, QUEENSQURY, NEW YORK 12801
(518) 798.4 72G
(518) 793-9777
Funeral Dirictor ��,�,�� �^
tame Xg r IM Case No.
Uate of Cremation 3 �.� ~
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TOWN OF QUEENSBURY 3
PINE VIEW CEMETERY
do
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
AUTHORIZATION TO CREMATE
'rhe undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulations to cremate the remains of:
Name
Raoul . J. Laroc(Sex)
Jr. male
Sex
265 Main St Hudson Falls NY 12839
Street City State Zip Code
who died on 26 day &f March 19 92
at Glens Falls hos ital Glens Falls NY
Place Address ——
Name and address of nearest living relative or name of person authorizing cremation:
Olga Laroc ue, 171 Main St , Hudson Falls , NY
Name Address
Relationship to the deceased ex-wife
Name of the funeral home Carleton Funeral Home Ing .
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his
or tier 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 a made against them by reason of, or connected with the cremation of said remains
as di ted, whether such claims or demands are, or are not, wholly groundless, false or fraudulent.
itnes Si nature o R
K at ve •r Legal Rep.
68 Main St 171 Main St
Hudson Falls NY 12839
dress ^ T Address
Signed on this date 3 U S Z