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Bottum, Moya
TOWN OF QUEENSBURY Pine View Cemetery nrtrl Cremn tort itnt 21 Qunker Rond, Queenshury, NY. 72804.5902 (518) 745-4476 (518) 745-4477 hcrp uwww queensbury net Funeral Director: C 14 la �,f� �o IA Name of Deceased: ,�'1,D 4 / *lv '130-Ti Case Number: © `Z_, Date of Cremation: Retort: (f,C-� Aw2c Q \Zr) Time Cremation Started: 2 'ice -v Time Cremation Completed: Type of Container: � ��(/ 1 !'�"► �'/�a � /j��yl.�.N L Remarks: �o 3 3�of4 � q 1 h Ho it of Nnittrn1 8enitty ... A Gnntl Plnie to Li r 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: Moya Bottum Female (Name) (Sex) 225 Burt Road Fort Edward,NY 12828- (Street) (City) (State) (Zip Code) who died on 9 th day of July 2005 at Residence Fort Edward,NY (Place) (Address) Name and address of nearest living relative or name of person authorizing cremations: Brant Bottum 225 Burt Road Fort Edward,NY (Name) (Address) Relationship to the deceased Husband Name of Funeral Home Carleton Funeral Home, Inc. IMPORTANT: I represent that to the best of my knowledge, the deceased has or as 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 Crematoriaif 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. 68 Main Street, Hudson Falls, NY. 12839 (Witness) (Address) 225 Burt Road, Fort Edward, NY 12828 (Signature of Relative or Legal Rep. and Address) Signed on this date: