Combs, Roger r
SOWN OF QUEENSBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director � /7Z?L�/v/-;
Name d ,:. )e-R �ffM1S Case # ���
Date of Cremation
Time Cremation Started 4Q1ti1
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Time Cremation Comoleted 1c /91
Type of Container �, �/��
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, in accordance with
and subject to its Rules and Regulations to cremate the remains of:
Roger Beecher Combs Male
(Name) (Sex)
Pleasant Valley Nursing Fac. Argyle,NY 12809
(Street) (City) (State) (Zip Code)
who died on 19th day of February 2002
at Pleasant Valley Nursing Fac. Route 40 Argyle,NY 12809
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Martha McMurray P.O.Box 1093, Bolton Landing,NY 12814
(Name) (Address)
Relationship to the deceased __ Daughter
Name of Funeral Home Carleton Funeral Home,Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or 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 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, 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 not wholly groundless, false or fraudulent.
(— �A 68 Main Street P.O.Box 67, Hudson Falls,NY 12839
(Witness) (Address)
C1 61JY (SO�rv� l r�i.�c /2 F1l/
(Signature of Relative or gal Rep. and Address)
Signed on this date: