Butler, Walter Jr. TOWN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director2�kg�d/f 00�;-Jl.
Name N / �� .DULL. XaCase 1! 1-34'
Date of Cremation s ` a — / 1
Time Cremation Started
Time Cremation Completed �. -
Type of Container (�/��,!/ ///l� Z5J / 7j��,��
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Remarks :
,14 e-R 0/ M
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TOWN OF OUEENSBURY
plN9 VIEW CEMETERY
CR mwroR I UM
pua►cer Road, quaensbury, New YorW 12FJ04 `J�
phpne (519) Crematorium 745-4477 or if no answer
Cemetery 714Z-4476
AUTHORIZATION TO CREMATE
The undersigned esquests and authorizes Pine View -Crematorium, to
accordance with and sub)ect to its Rules and Aegulations to
cremate the remain* of:
Waiter D. i Butler Jr, Male _
(Name) (SV'x)
Box ?Be Sar1{on Mines Rd. , North River, N.Y. 1.2856
(Street) (City) (State) (Zip Code)
*he died on 18 ` h. day of 1997 ---�
at
(Place) (Address)
Name and address bf nearest living relative or name of person
authorizing cremationi
TrSmmC.1].._3.41 Aelam T)r_.
(NAme ) (Address)
Relationship to the deceased Sister
Name of Funeral Home�A]exa,nrior >• ineral -Hamm. ft. 7Aj Nn_ _Riv r. N.Y. 19V6
I MPU RTANT s
I represent that to the best of my knowledge# the deceased �
has no pacomaker in his or her body. (Circle One)
I certify that I have the full power and authorisation to arrange
for the cremation of the remains and to direct .the disposition of
the creai,tea rgm&ins, that any personal possession• have either
bee* r#xQyWd or May be destroyed, and agree to protect, defend
and save harmless Pine View Crematorium from any and all claims
and ormands for loss er damage% 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
groan less• F s ar fraudulgmt.
i/.
Sz'+'
_ r
(dfts) (Address) 7�z)
- -
(Signature of Relative or Legal Rep. and Address)
Signed on this datesQ.f'�-�.�