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Wrigley, Andrew Commonwealth of Pennsylvania J I _,` _��/_ - _ Burial or Other Disposition Division of Vital Records ,J J �j �J of a Dead Human Body Full Name of Deceased Date of Birth Age Sex Date of Death R jJ (),R Q.. l.tiJ R I L_, I C-N fJJ ��JA , fit . d i Cause of Death Veteran Status Race , /� (Yes or No) ✓* i w N 6 11-1 1-4 I r Jr; Place of Death City,Borough,Township County Authorized Disposition(Check appropriate box) Name of Common Carrier Burial Cremation Humanity Gifts Removal Shipment by Common Carrier I 3,'...-1 I I I I I I 1 1 Disinterment Date of Disposition Name of Cemetery or Crematory �: County(If in Pa I �j y ) Reinterment Address City,Borough,Township .N \d I certify that I have met all the requiremen s of the Vital Statistics Laws I certify that a Bath certificate has been filed as required by laws of the and Regulations. state. Permission is hereby given to the Person in Charge to transl port J/L,A,L,„_.1 ------ C and/or make final disposal of the remains. Signature of Person in Charge of Interment / rA tr. '3'1;23i17 94,,,,-72 7.. -, 7a e.e .) Address ' nature of Registrar Dare Issr '— Mail To: I certify that the deceased name above was buried or cremated in the cem or crematory named. Division of Vital Records P. O. Box 1528 o-ecidrk�,,, r Jr f-76' New Castle, Pennsylvania 16103 Sign ure of Cemetery Of col Data AI e t/ rr J `.p r►.-e reL� q k! e G Cf( Address u c;N S See Reverse Side for Regulations b I Wrigley Lot No. 43-E ddress 29 Marcy Lane Queensbury NY 12804 Section No. wner Douglas Wrigley Plot Mohican late 8/1/95 Approx. 67Superficial ft. @ ocation Bounded North by Vacant , South by Robelen , East by Bowen , West by Vacant , orner Posts .emarks Peed No. (and changes) 2682 ayment Record Paid in Full 8/1/95 ( $7 0 0 . 0 0 ) record of Interments �C) \t . t a Q cz:k,q)(1,.5 A ),LCRn1�, t© � as h r� x1 Virginia A. Wrigley/1/95 V W m a A Andrew Wrigley 4/30/96 b )( S I N L N r X I . � oW�N Form No. 01 17t11V1 L:. Wrigley, Andrew Age: 5 Months Cs) Cause: Natural Lot Owner: Douglas Wrigley Lot # 43-E Mohican Grave # 2-A Case # Concrete Died: 1/59 Interred: 4/3 0/9 6 Undertaker: PA Div . of Vital Records