Wadleigh, Harry Jr. •1
TOWN OF Q UEENSB UR
Pine Virtu Cemetery and Creutatorium Y
11 Quaker Road, Qutenshury, NY. 12804.5902
(S 18) 745•4476
hirP:ii�v.queensbu (S18)745.4477
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Funeral Director,
Name of Deceased:
Case Number.
Date of Cremation: 2 �,
Retort: ;tiw o
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Time Cremation Started: Of
Time Cremation Completed:
TYPe of Container. 0001
Remarks:
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" Houle of Nntural Beauty ... A Caad Place to Lire '
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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 Pkre View Crematorium,in accordance with and subject to its Rules and Regulations to
crerrmte the rerrakts of .
U-
UA57-
(State) (Zip Cam)
(Street) (City) / (_
who d onday of V k �
at (� )
(lam)
Name arW address of nearest rn V ralaliwe or name of person auurori¢irq I r
(Name) ( ) OIL
Relationship to the deceased
Name of Funeral Home -
IMPORTANT: the deceased(has)or rat maker.detb Netor,battery,battery peck.power
Dell,radioactive knplant or
I represent that to the best traadioec Live devic my e in his or her body.(C
I certify that i have U power and udwrW&n to arrange for the aenration d the rerrtairrs and b direct the disposMion t, the
cremated reflaim that arty persona!possesdane ton eM w been wmoved or may be destroyed.and agree to proteri,defend and
save tranrrfe�Pine View Cremel or do 9
by Anso Of e crer nledon�roam* dared �er�such de arvA*:h way e or not ly made agskO Woundless.isles or Aj/.
(Signature and Address of Relative or Legal Represerviedw)
Signed on this date
Disposition of Cremated Rona=
I hereby direct Pine View Crematorium to dispose of the cremated rarnairw aS WOW.
Marl to
other arrangements-Please specify-
If WWwWWon of cremated remains is requested.check here
Revision:April 18,2W7