Butterfield, Thomas L O OF
(,,. Pr.NE V( QUEE9\�5tBU
E�' CEMETERY AND
CREMATORIUM
QV"-ER ROAD
QIJEENSBURY, NE1•y YORK 12804(518) 745.4476 (518) 745.4-477
Funeral Director
Fame
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C8Se#, t u
Oa•te Of Cremation
Time Cremation Started 00$
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7 : me Crema
lion Completed
46
Ty ?e of Container
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Remarks
1
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 undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
44
(Name)
r-- ^.
1
I
' Code�`I
(Street) (City) (State) (ZIP )
who died on day of ��� r 20
at .- o6pl r
( ) (Address)
address of livipg relative eif namg of person authorizing cremation:
4rVL \-- � , - Ili-.
(Name) r(+�ddress)
Relationship to the deceased
Name of Funeral Home
IMPORTANT: the deceased(has)one��er'defibrillator or any other battery operated
I represer►t that to the best of my Ivrowledge,
device in his or her body. (Circle One)
I certify that I have 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 Cremstanium 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 or are not wholly
groundless,false or fraudulent.
(Witness) (Address)
X, p (SigmWre.end.-A ddress of-Reiative or Legal Representaini
Sid on thisdate: + �-
Disposition of Cremated Remains
I hereby direct P'ne View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006