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Combs, Charlotte O PINE V�/ F QUEE9\�SrBUr IEW CEMETERY A� QUAKER ROAD CREMATORIUM QUEENSBURY, NEW YORK 12804 (518) 745.4-476 (518) 745.4477 Funeral Director Name Case#. (W3 Date 0f Cremation r � Zo© Time Cremation Started Ito-;3W h T =me Cremation Completed ' Type of Container 41 12�1 Remarks p�Y It IsT C S d # Town of Queensbury Pine View Cemetery and Crematorium 21 Quaker Road,Queensbury,New York, 128O4 Cemetery Oifice:(518)745-4476,Crematorium:(518)745-4477 Authorization to Cremate The undersigned requests and suftrtws Pine View Crematorium in accordance with and subject to its Rules and Regulations to crenate trp rerra>hs d A n S F1e�r►a.t9- (Marne) (SOX) U31y r n-k Rd ti. y 2c -I (mot) 4-41 (coy) (state) (zip code) who died on day of SIPA fU'� hc�rn� Ca1x�►�e (Pla* O Name and address of nearest MV relative orname of Pam agwrt*Vcremation: M I(Name) (Address) Relationship to the deceased. 'i I' Nana of Funeral liana� ,���a/i d 'b IMPORTANT:I represent that to the bell of my the deceased(has)or( as h no)pacemaker.delfbpackpowerriAaior,battery.battery p •p cell,radiosi Implant or radloacxive device in his or her body.(Circle One) I certify that I have to power and autlrorttaion W orange for 00 aemetlon of the remains and 10 direct the melon of the cranai remairm that any personal possessions tave either been rernoind or may be destroyed.and agree to prated,defend and View save harmlessen rn y ma� a ade ra ror rwtma fee=oforcn wtl de ww false or fiaudulern. � S ( ) (Address) (Signature and Address of Relative or Legal Reprsser►tative) Signed on this date: �VQ 8 Disposition of Cremated Remains I hereby direct Pine View Crematorium to dispose of the Cremated remains es Mows: NW to Other arrangerni-Please specKy: if pulverization of cremated remi is requested.Check here Revision:April 18,2007