Wordelmann, Mary rrO r��NFQUEE9�5BU-r�y
PINE VIEW CEMETERY q
WAXER ROAD, � CREMATORIUM
QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
I Name
C'C.
G� j nw Ca
se q .�
Date Of Cremation
100'7
Time Cremation Started
Time Cremation Completed
11, 30
Type of Container a� oqtr1
Remarks
6U" :uvh
Tom of Queersbury
Pine View Cemetery and Crematafizrm
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium-. (518)745-4477
Auftx zedon to Cremate
The u dwWgns0 requests and auft*taes Pk*V%w Creamforlum,In aamrdenoe with OW VAJect to ks Rules and Regulations to
crenate the remains of
Mary Wordelmann F
(Naffle) (SWO
71 3 1,Jr'44 1, Poe,L kt L( /Z S19
(Stnw) � (Cky) (tea) (Zip ram)
whodledon The loth day of October 20
at Glens Falls Hospital Glens Falls NY
(Place) (Address)
Nance and address of nearest Ruing r+el Wit or name of person ataho k&V aemerion:
Megan Wordelmann
(Name) (Address)
Rek�10 ft deed Daughter
NaroofFtw alFkx. Carleton Funeral Home, Inc.
IMPORTANT:
I repreaerrt that to the beat of my knowledge,the deceased(hm)or(has no)pacemaker,deftF11etor,ba kffy,beuery petit,power
ceN,radioectire i.Vfttt or n0oarive device in his or her body.(Ckde One)
I of*VW I have f A power and w0wrtzndw w enact *for the aWraka of the remains end to dirtrct the diepoeftm of the
cremated remains,that any perso►W pew have eWa been removed or may be deshaved,anti agree to prefect,defend and
save hWMW8 Pine View CrW*b*1M from arty end all claims and demands for lose or damages which may be made ageiret them
by reason d or conrteMd wkh if n cremation of add rsmafrta as dheNed,wlblNer such claims ar demands are or ere not wholly
or
c 68 Main Street, Hudson Falls, NY
(tlYkrt�s) (Address)
Address of Relative or Legal RapreseMetMe)
Signed on this date:
Dbposkion of Cremated Rernekre
I hereby direct Pete View Ctematahrm to dispose of Use cremated remains as Hollows:.
Mail to
Other arrangerrrents-Please RMK*
If pulveri s ion of aremaW remains m requeeW,dm cic here XX
RevN iam April 18,2007