Butterfield, Clyde fc
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PWE y\�.I J QUEE9\�50UTr/y
�'TEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745.4476 (518) 745.4-477
Fam Funeral Director
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Ttme Cremation Completed 3i3u pM1
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Ofte: (518)745-4476, Crematorium: (518)745-4477
Authorization to Cremate
The undersigned ragrrests and&*vxtaes Pate View Cremetorlum,in accordance with and w*d to Its Rules and Regulations to
cremate the remains of:
Clyde C. Butterfield M
(Name) (Sex)
Fort Hudson HCF, Fort Edward, NY _
(Street) (City) {state) (ZJ p Code)
who died on 19th daYd Sept. 2008
at Fort Hudson HCF, Fort Edward, NY
(Place) (Address)
Name and address of on me IMM r+elatrve or name of person outttort&V cremetiort:
Charlene Harrington 29 maple St. , Hudson falls, NY
(Name) (Address)
Relationship to the deceased daughter
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the beet of my kwMedge,the dscessed(hss)or=pm no) ,detibriAattu,battery,battery peck,power
cell,radioactive implant or redioscove devios In his or her body.(C
I c ertiiy#vK I I revs full power and suawrt;etion to arrange for the cremation of be remsins and to OWW the deposition of the
cremaW remains,that any personal poeeeaefom have ahhar been removed or maybe destroyed,and agree to protect,defend and
sere harmless Pine View Crerml0dum from any and all ciaims and demands for low or damages Wild maybe made epaitvg them
oyipeson of or connected whit tits cxentetion of said remefrts as dkWed,whether such dab, or demands are or am not wholly
false or tlpudtrlar*
68 Main Street, Hudson Falls, NY
(Wiliness) � (Address)
Maple St. , Hudson Falls, NY
pgriaturs and of Relative or Legal RepresentakNe)
Signed on this date: (i2( / '4"
Dispositlon of Crernneted Remains
1 hereby direct mine View Crenratorkim to d1spose of bs cremated remains as follows:.
KW to
Ober anarVements-Please specify:
if pulve&Wion of cremated remains is requested,dv&here XX
Rerviskur.April 18,2007