koumbis, Ioannis Qurzrz9�'r-Z3UT,_T
PINE `YqEW CEMETERY AND CREMATORIUM
QU&KER ROAD, QUEENS6URY. NBW YORK 17804
(518) 745.4476 (518) 745'•4477
Funeral Director
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Name lURr� �3
=a . e Of Cremation June BoU7
� .!-e Cremation Started 7 '" 1p
Cremation Completed
;e of Container ` r"CL,rU Tt ^
remarks
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Town of Queensbury
Pine View Cemetery and Cremabffium
23 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477 '
Authorization to Cremate
The undersigned requestn and su lhoit es Pine View Crem slodum,In aaoordenoe with Arad*A*d to ks Rules and Regulations to
aentate the remains at
Ioannis Koumbis M
(Name) {Seoc)
122 Gilchrist Hill Road Hartford NY 12838-
(Shiset) (City) (St") (Zip code)
who died on loth day d June 2007
at Glens Falls Hospital Glens Falls NY
(Place) (Address)
Name and address of nearest Iiving r+elt"or name of person au twrtring cremation
Mrs. Donna Koumbis 122 Gilchrist Hill Road
(Name) (Address)
Relationship to the deed Wife
Name d Funeral Fkme Carleton Funeral Home, Inc.
IMPORTANT:
I repave it that to the beat of my knowledge,the deeeasexl(has)or
i defibrpator,bat ery,battery pack,pow
ca,radioactive k qAw t or raad"i ec0m device in his or her body.(C )
I oartily that I have fiN power and oudxwb etlon to arrange for the cremation of the remakae and to d W the dspostion of the
cremated rameins,that any personal prig sesski , have ekfmr lea n removed or maybe destroyed,end agree top defend and
save hermMae Pine View Crsmabxkj rr from any and all claims and demands for toga or dwv pss whfdt may be made against them
by reemn or or coonneeciedd wwfth 1f m cremation of add remelrta es dire0ed,whether such do'nts or dmmarrds are or are not whWy
groundless,lahm or 11raudukut.
68 Main Street, Hudson Falls, NY
(wuness) (Addr+en)
122 Gilchrist Hill Road
o r(S vSigrwureW and Address%)y�of Relefive or Legal RepresaMetMe)
Signed on this date:
Disposition of 0arriated Remains
I hereby direct fine View Crenm*wlu n to dispose of the cremated remains as follows,
Mail to
giber an arage►nents-Pleeae"MCKy:
if pulverization of Cremated namains is retfuested,check here XX
itevisian:April 18,2007