Raymore, John OF QUEEN
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k PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_'�ExAlg
Name ® Case #
Date of Cremation
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Time Cremation Started i AM/
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Time Cremation Completed _t ,.-70A ,-M t
Type of Container Gh,/?.O
Remarks :
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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 ,
accordance with and subject to' its Rules and Regulations to
cremate the remains of:
John Raymore Male
(Name) _-. (Sex)
PO Box 74, Minerva, NY 12851
(Street ) (City) (State) ( Zip Code )
who died on 23rd day of June 19 99
at Glens falls Hospital
(Place) (Address)
Name and address of nearest living relative or name of pers :,-,
authorizing cremation :
Alice Coon, Box 322, Bolton landing, NY 12814
(Name ) (Address)
Relationship to the deceased Sister
Name of Funeral Home Alexander FH, warrensburg, NY
IMPORTANT:
I represent that to the best of my knowledge, the deceased XNXXXXk
has no pacemaker in his or her body. (Circle One )
I certify that I have the full power and authorization to arrange
for the cremation of t-he remains and to direct the disposition di6si�'
the cremated remains, that any personal - possessions have either
been removed or may be destroyed, and agree to protect , defenz
and save harmless Pine View Crematorium from any and all c ' a '. +ms .
and demands for loss or damages which may be made against them
reason of or connected with the cremation of said remains as
jd ec d whether such claims or demands are or are not wno : . •
groun ss, false or fraudulent .
Warrensburg, NY
(Witness) (Address)
Same as above
(Signature of Relative or Legal Rep. and Address)
6-24-99
c; r,.,oH nn this date :