Weller, Harold f
�O O
F QUEE9�.(5�BUr,��PWEYIEW
CEMETERYquA AND K CREMATORIUM
ER ROAD, Q p,�.rsg�Y NEW YORK 12804
(518) 745.4476 (518) 745.4437
Funeral Director
Name arulj I
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Oace Of Cremation SSA
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Time Cremation Started
Time Cremation Completed L}q� P
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Type of Container Ct C,:
Remarks
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Town of Queensbtlry
Pine View Cemewry and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745.4477
Audmizabon 110 Cremate
The undersigned requests end aulh ftn Plne View CPen,e&arum,in a000raenoe with era a #sd to tts Rules and Regulations to
cremate the remeine of:
Harold Irving Weller M
(Name) (Saco
210 Moreau NY 12828-
(Street) (City) (State) (Zip Code)
vAm died on d9Yd 12/02/2008 20_
at 210 Reservoir Road Moreau NY
(Place) (Address)
Name and addraew of an me living r eletive or now of person ehrthorb ft cremation:
Mrs. Janet Weller 210 Reservoir Road
(Name) (Addrew)
Reiatior**to ttre deCeesed W i f e
Nano of Funeral Fkw Carleton Funeral Home, Inc.
IMPORTANT:
l repr+eserrt that to the beet of my lawwledpe,the davesed(alas)or Om no)per,deftff*GW,boary,banery pack,Pmw
cell,radioactive irnpterd or rsdloactive device in his or her body.(Cirde One)
1 oar*that i gave hA power and su0hartsetton to arn!"W 10r tha aentetloa of the ram eft and to dVW the disposition of the
cremated rwr airw,that any personal poeseedwo have ONO" An removed or maybe deshvied,end apse to protect,defend and
save henv*w Pine View Cret OmIum 6om any and al deims and demands for lase or damages Mich maybe made against them
by reason of or aonnecied wflh the cnmwUan of odd semefne ae dked4 whether such daNhhs ar is- a-de arse or are not wholly
groundless, or ffeudt knL
68 Main Street, Hudson Falls, NY
(Address)
(,2
10 Reservoir
(Sipnetuv ara Address of Re or legal pepresentetive)
Signed an this date:
DbpwWn of Cremated Rematne
I hereby dared Pine View Crereetoriun to dispose of the awneod remebw as f lows�
Mw to
outer auwVwnents-Please WOW
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If pulveraetion of Cremated remains is mq)ested,dw&here XX
Pkawk ion:April 18,2007