Butler, Eleanor 70rNIN 0F QUEENB UT�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK i2804
(518) 745-4476 (518) 745-4477
Funeral Director_ RtiKer
Name Ele1%o'er /� l�u�)er
Case# _ 37t7
Date Of Cremation A') usr 31 2007
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Time Cremation Started g•_bo
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Time Cremation Completed lo :ivgM
Type of Container �irc b��J Crtiw ��
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Remarks
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c_00i 10 w 16 AM
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Authorization to Cremate
The undeYsr9rted requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
L tC, N o rZ t1 7'GG-�-� �1yAc cam
(Name) (Sex)
z e& ffl, SJ. R� 9 �"« C-v2 G C- _X) y /2-00 -
(street) (City) (s� )
who died on iZ 9 day of U S 20 p '7
at
(Place) (Address
Name and address of nearest living relative or name of person
/`DQ 'RL. 1^CCi tf76a�1�
(Name) // (Address)
Relationship to the deceased /kS rS !4 Al Y,
Name of Funeral Home a �l4lGLr� rv�
IMPORTANT*
I represent that to the best of my knowledge,the deceased(has)or�aoemaker,defibrillator,battery,battery pack,pourer
cell,radioactive implant or radioactive device in his or her body.(Circle
�ne)
I oertity that 1 have fun power and authorization to arrarW for the cremation of the remains and to direct the dispostiont of the
cremated remains,that any personal possessions have altar been removed or may be destroyed,and agree to prole«,defend and
save hamdess Pine View C ren varNxn from any and all dairtts and dennands for loss or damages which may be made against them
by reason of or connected wit the cremation of said reateins as directed.whedw such claim or demands are or am not wholly
grounV
a
404Z (WI U ( )
V�.'f 9 Z- X-j
(Signat6fe and Address of Relative or Legal Representative)
Signed on this date: P 12-S /0 7
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please spew
If pulverization of cremated remains is requested.check here
Revision:April 18,2007