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Morrow, John TOUN OF QUEEVBU9�Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name yCJ /��/�(�/( Q�f Case # Date of Cremation - 9 -9� Time Cremation Started f � Time Cremation Completed Type of Container Remarks : SENT BY:Me, HARVEY S KALNITSKY; 7- 6-93 ; 8:16 ; 5142666550-4 ;# 2 TOM 13F MMENiSBI MY PINE VIIEW CEMETERY a CREMATOR IUM Gmdkar Road, Queensbury, Now York 18804 Phone (518) Crematorium 745-4477 or if no ahsw*r Cemetery 745-4476 AUTHORIZATION TO CREMATE The undersigned requests and authorises Pine View Crematortuml in accordance with and subject tv its Rules and Rtgulatiehs to cremate the remains Ofl John Ncr=w Ma19 (Name) (8e0 iatr•owt) .. (City) (state) W (lip�Coode) who died on 5th day of July at Glens Falls Hogital. Glans Efile, Now York iplace) iAddress) )lame 0114 +%Jr•av3 of nearest liviwe relative or name of porann authorising cremations tmrnnnn Mr.0nillmn 360 9L. jalms St. Montreal, Queboo. Cenede (Name) (Address) Relationship to the deceased Nephew Name of Funeral Home Regan A penny, Funeral Service, Inc. 3MOORTANT: I re *sent that to the best of my knowledge, the deceased has or has n9 pacemaker in his or her body. (Circle One) i certify that I have the full pawls and authorization to arrange for the cremation of the remains and. ta direct the disposition of the s:rematod remainsg than any personal possessions have either even removeu wr- mwy u• 4ias6r urwal �...1 .oljoam to protesq, +(ra•wd and Bay* narma*ss WLne VLvw Cr-rwra6we imn l•s WN W11r and all rlasims and demands fnr to%% nr damages which Roy be made agat"et them by reason of or connected with she cremation of said remairrl► as directed whether such claims or demands are or are not wholly groundless, false or fraudulent. «site• s) Ifiddraaal or- S�. Sins Safi MortccoLQ (Oipnatu of RePiptive or Legal Rep. and Address) Signed on this datol July 6 1993 ay ip!; NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Vital Records Section Name First Middle Last Sex John ___ F: ........ .... . . .....:male_ Date of DeatFlul 5 1993 Age 613....... If Veteran of U.S. Armed Forces, `J1 y War or Dates no Place of Death Hospital, Institution or W City,Town or Village City of Glens Falls Street Address Glens Falls Hospital n Manner of Death Natural Cause Accident Homicide Suicide Undetermined Pending.. ................ Circumstances Investigation ... .:........................................._ ..................... .... ..... Lti Medical Cert'rfier Name Title © David W Schwenker MD.::::::..... . _ _......... _ ......... .... .:::: .. ... Address 90 South..Street:, _:Glens Falb .....New: Yor.k::12.8.0.1...... Death Certificate Filed District Number egiste Number City,Town or Village City of Glens FallsG�l� / 7 , Date Cemetery or Crematory ❑Burial Jul ..8, 1993 Pine ViewCrenatp. Y .. ...::.r ..... .. . ®Cremation Address Queensbury.,. New. York_ Z Date Place Removed O', Removal and/or Held I- and/or Hold :.:::... : ... Address N' 0 ........ ....... . .. . :::..... ......... ......... :...... CL Date Point of N; ❑Transportation by Shipment p; Common Carrier ............ .. Destination . _......... ....... .. ._ - - .. _ _::::.:._::. Disinterment Date Cemetery Address .. . .... _. ....... Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Firm Regan anal Denny Funeral Service, Inc. 0:1,5.83 Address 26 Quaker Road, Queensbury, New York 12804 ...... Name of Funeral Firm Making Disposition or to Whom 2.1 Remains are Shipped, If Other than Above Xir . . .:: ........... .... ........ ...... .. ......::: .. -::::.., Address ....... ... . . Permission IR hereby granted to dispose of the hu an re ains described above as indicated. Date Issued i Registrar of Vital Statistics 1 r � (signature) District Number C Place L1,-Uri I certify that the remains of the decedent identifie above were disposed of in accordance with this permit on: Z Date of Disposition 7`9"p Place of Disposition /�'l j/NCC !' "C &jrfw�C1 LU (address) 2 LU Cl) (section) (lot number) (grave number) p Name of Sexton r Person i Charge of Premis s 'Z (please pent) � W Signature Title �"J11%� _, '�/ ' DOH-1555 (10/89) p. 1 of 2 VS-61