Combs, Albert OF QUEEN,5DUr��
PINE VIER' CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.-4.477
f L Funeral Director
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Date Of Cremation
Time Cremation Started
SU
T . me Cremation Completed
'ype of Container Lticcl�j�c,r�
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Remarks
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Town of Queensbury
Pate View Cemetery and Crematorium
21 Quaker Road,QueensbM,New York, 128M
Cemetery Office: (518)745-4476,Crematorium: (518)745-4477
Autiwdze ion to Cremate
The urtdersigrted requests and atrtlxxtaes Pate View ccemaRor ,
in amordance with and%4W to its Rules and Regulations to
Df-
cretrrateLt��FLr�. /���
1yYJi
(Name) fS�
n (Zip code)
( ) (�)
who deed on 213��
Odorless
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Name and address of neatest Wftrelative or name of personauthorujng coon:
(Nam)
RekdWistp to the demmed , I
Name of Putters!Horne . �.�����t 1l DA 4_t7 —
IMPORTANT: the deceased( �W) deftdftw or arty other battE Y operated
I representthat to the best of my taowledge,
devioe in his or her body. (Ckda One)
1 certify that I have fud power and authoriz8tim to 8ffsngs for the cre ma"on of the mnaats and to direct the dmposmOn of the
ff8mgjgd rernaIm.duo any personal have either been removed or may be destroyed.and agree to Proms,defend and
harmless Pine View��aid all dairm slue derrtartas tior low of which rrmy be medo against them
saw by reason of or connected wkh the a of said rt3rr dm as dkecl➢arl.whether such ciai its or demands are or are not wholly
hiss, or hauduient.
(Address)
(Spnature and Address.of Relative or Rom)
Signed on the date:
Disposition of Cremated Remains
i hereby direct trine View Crerrtatftrk"to dispose of the crernated mffm is as fdtonts:
Mad to
_ .MLkuse. +0 s d-rhUc
orr>er arrarreeme� -
if pulverization of crernated remains is reed•dwpck here— --
Revision:January 1,2006