Busch, William C Jr. L O OF QUEENs5BU.9Zy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
' P Q �c7 LFuneral Director , 4jcxA1vn1-P
Name 4J j,�� r7/� L�(IjG �l /C , Case # 1 3
Date of Cremation
Time Cremation Started b i ►4'[y A !M
Time Cremation Completed 9�Cn
Type of Container0rg/1 ��1��� �J��;G/�J•�-®/�-7-t�i�-���
Remarks :
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TOWN OF QUEENSBURY f,
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518) Crematorium .745-4477;(if no answer)
Cemetery 745-4476
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:
William C. Busch Jr. Male
(NAME) (SEX)
Rt 9N, Diamond Point, NY 12824
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 26th day of November 2000
at His home (same- as above)
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Mrs. Carla `B. Burhoe Canoe •I'sland Lodge, 3820 Lake Shore Dr. , Diamond Pt, NY
12821
Relationship to deceased Daughter
Name of Funeral Home Alexander Funeral home, Inc. , Warrensburg, NY
IMPORTANT
I represent that to the best of my knowledge, the deceased$gmhas no pacemaker in his or her
body. (CIRCLE ONE) .
I certify that I have.the 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
Crematorium from any and all claims and demands for loss or damages which may be made
mst the by reason of or connected with the cremation of said remains as directed, whether
such claim
emands are or are not wholly groundless, false or fraudulent.
John S. Alexander Warrensburg, NY
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: 11-26-00