Johnson, William ' w
rrn
J- �-/ OF QUEE9�5OUrp
PINE
' IE'W CEMETERY AND CRE
QUAKER ROAD, QUEENSBURY MATORIUNv1
(518) 745.4.476 ' NEW YORK 12804
(518) 745-4-477
Funeral Director (�
Fame
Case#
_ a-Ce Of Cremation
Time Cremation Started
7 =me Cremation Completed
Type Of Container
Remarks S^
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Town of Queensbttry
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477 '
Authorization to Crerriate
The undersigned requests and&Aw taea Pine View Crematorium,In accordance v*h and subject to Its Rubs and Regulations to
cra vwe the remains of:
William Daniel Johnson M
(Nerve) (Sect)
2.09 White Burch Estates Fort Edward NY 12828-
(sbvd) (CRY) (Stets) (Zl p Cam)
who died on day of 09/08/2008 24_
at Route 197, Town of Moreau
(Piece) (Address)
Name and address of nearest living r*Wm or name of person auowxt np cremation:
Amy Johnson 209 White Burch Estates
(Name) (Address)
Relationship to the deceased Wi f e
Name of Funeral tiorne Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to fha best of my knowledge,the deceased(hm)or(m 96)Pacemalw,60%dietar,baterY,ba"per,power
080,radioactive implant or radioactive device In his or her body.(Clyde One)
1 oertily that I have AA power and sut1xwtmtlon to anange for the crenv*0 of the remains and to direct the disposition of the
cremated remains,that any personal possessions have eM Km beery ranoved or may be deft oyes,and agree to protect,defend and
save harmlass Pine View CremaliNium from arty and oil tiaims and demands for foss or damages wFdch maybe made against tltern
by reason d or corwmaod wilt the cramattm of said remains as directed,whether arch rim' a ar d e 'a ds are or are not wholly
=false or IM
68 Main Street, Hudson Falls, NY
(Address)
209 White Burch Estates
v 0 n u 77a���.
and Andreas of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as f lows:.
Mail to
Other arrangwnenta-Please spaclfy:
ff pAver zaticn of cremated remains is re Wested,dredc here XX
R&vi m-.Apri118,2007