Holcomb, Howard TORN OF QUEENs5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name kJ // d �� Case #
Date of Crematicn--4----,-�— e?7
Time Cremation Started O'/ ��)011
Time Cremation Completed ���?�� I / ���
Type of Container 4',ZLEZd.�1,'2 4 /
Remarks :
141 Ai N
1� 11 g'34 09 A
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:
Howard L. Holcomb Male
(Name) (Se.x)
172 Buttermilk Falls Rd. Fort Ann New York 12827
(Street ) (City) (State) ( Zip Code )
who died on 30th day of April 1999
at Albany Medical Center Albany, New York
(Place) (Address )
Name and address of nearest living relative or name of perscn
authorizing cremation :
Mrs. Gloria Holcomb 172 Buttermilk Falls Rd. Fort Ann, NY 12827
(Name ) (Address)
Relationship to the deceased Wife
Name of Funeral Home Alexander Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased �X
has no pacemaker in his NYXXWK 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 , defenc
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them o�
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wnoli ,
groundless, f 1 or fraudulent .
(Witness (Address/)
(Signature cift Ffelative or Legal Rep. and Address)
Signed on this date : May 1, 1999