Combs, Lida rrO RN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director &EA- 9x—aEn
Name % �A5 Case #
Date of Cremation //— /s--o?Coo
Time Cremation Started a("T-5—A / MI
Time Cremation Completed jf 33—f j Nj t
Type of Container C��'l ?790/ z D
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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, in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
Mrs. Lida Combs Female
(Name) (Sex)
155 Bowen Hill Road, Warrensburg, New York 12885
(Street) (City) (State) (Zip Code)
who died on the 12th day of November 2000
at The Glens Falls Hospital - Glens Falls, NY
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Jerrold A. Combs - Golf Course Road, P.O. Box 11, Warrensburg, N.Y. 12885
(Name) (Address)
Relationship to the deceased Son
Name of Funeral Home Alexander Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased XXHKKdX
has no pacemaker in bjMogM her 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 dispositioD 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 be made against them by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
grou dless aW fraudulent. bah-G1 G,ra✓et
AMU 3809 Main St. , Warrensburg, NY 12885
(W' tn s ) (Address)
(Signature of Relative or Legal Rep. a ddress ) ,
Si ed on this date: