Boucher, Philippa rrnT�N OF QUEEVBU9U
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
I Funeral Director I-TLM 2
Name {�h, IT, �uvC, r- Case # NL
Date of Cremation U ,,� 22 , 70A
Time Cremation Started
Time Cremation Completed
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Type of Container �41 f7 on
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Remarks :
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34
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 Cremate the remains of: with and subject to its Rules and Regulations to
_Philippa Boucher
(NaC� Female
e
m
325 Broadway, Fort Edward, NY (12828
(Street) (City)
who died on 1 6 t h Gate) (Zip Code)
day of July 20 09
at Fort Hudson Nursi
(Place) ng Home Fort Edward NY 12828
(=ress)
Name and address of nearest Im e
, Person au<hom-inQ cremation:
Kathryn Boucher lotEMay Fort Edward(Name) (��) NY 12828
Reletionsho tothe —
MnthPr
Name of Funeral Home M.B. Kilmer Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) ( np
device in his or her body. (circle one) maker,defibrillator or any other battery operated
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, any personal Possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and
demands by reason of or Connected with the cremation of said remains as di for koss or damages which may be r against them
directed,
groundless, or lent, whether such claims or demands are or are not wholly
ignature and we or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine Vow Crematorium to dispose of the cremated remains as follows:
Ito
If pulverization of Cremated remans is requested,deck here
revision:Janr,ery 1,2006
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