Butler, James OF QUEE9�5TUr��
PLNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745*-4.477
Funeral Director
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� Case# 13
Date Of Cremation
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Tame Cremation Started
T .me Cremation Completed
Type of Container h n
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queenstwry,New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Authodizatlorr to Cremate
The undersigned requests and auftmes Erin view Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of•.
Mr. James J. Butler M
(Name) (SOX)
18 LaClaire Street, Hudson Falls, NY 12839
(sty) 12/31/2006 (CIW (State) (Zip Code)
who day of 20�
lGlens Faiis Hospitai Glens Fails —7M'
at
(Place) (Address)
Name and address of neareat WAM relative or name of person authoriuq cremation:
®o Act- 3313 61e.*ws <16 M Y-
(Name) (Address)
Releft el 1p to tha deceased C3wan.�1.• ",►�'
NemeofFuneredHome Carleton Funeral Home, Inc.
IMPORTANT:
I rapreaert that to to best of my knowledge,the deceased(has)or as r maleer.defib filial r or any olt►er betWy operated
device in his or her body. (Cirds One)
I cengy that I have full power and au8rortzmtion to arrange for the crerrretion of the remains and to direct the disposition of the
cremated remains,that any peraonat possessions have either!roan reegved or may be destroyed,and agree to protect,defend and
save harmless Pine View Cron oaiun from any and all dab. and derv, Is for loss or damages which may be made against them
by reason of or eon necled with the creankm of said remains as diedad,whedher such claims or demands are or are not wh*
Woundless,febe9r ftsudulertt.
(Wdrtess) (Address)
of or L )
SWwd on tfds date:
Disposition of Crerneted Remains
I hereby direct Pine View Cremoodum to dispose of to cremated remake as follows:
MON to
curer arrartgemerds-F'ieeae epatiry:
If pulveraabon of cremated remains Is requested,drerlc here XX
Revision:Jarwary 1,2006