Combs, William TOWN Y Y N OF QUEEVBUrky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /—
Name 1 lg,m wmb5 Case # 'I ! '/'
Date of Cremation // 0
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Time Cremation Started
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Time Cremation Completeds� ��f1Mi
Type of Container /5ri4 &5� <3
Remarks:
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TOWN OF QUEENSBURY 1
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 :
W(u(/j'1 W . G'jMQ S �
(Name) (Sex)
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(Street ) (City) (State) ( Zip Code )
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who died on jS-IL day of bVt.hn ��✓ 19�
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(Place) ( dress)
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Name and address of nearest living relative or name of person
authorizing cremation : )
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1 I 4, (o m b,3 -/ E l m 7YP 4(Name) (Address)
Relationship to the deceased �5bn
Name of Funeral Home �ppr— ��r-T -.4—
IMPORTANT: ,
I represent that to the best of my knowledge, the deceased-fTa-7—
has no pacemaker in his •bt--rer 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 , defena
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against then+ n`,
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
round s, false or fraudulent .
(Witness ) (Address )
(Signature of lative or Legal Rep. and Address)
Signed on this date : r�-lS -99