Weller, Jessica TO Tl/�� 0 QU
P rx� yr��v J�B U 1QQ•'
CEMZ�TERY AND CR2MATORIUM
�v�1KPR ROAD Q( EENS9URY,
(S18) 74S•4.476 NE�v YOR}C �280a
(518) 745•.4.477
F nera l
same Director
Case #
=ace O( Crematl.on �
3 Zo a�
T " e Cremation Started
Time Cremation Completed
Tree of Container
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rA f
Town of Queensbury
Pine Yew Cemetery and Cr+ematodum
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477 '
Authorization to Cremate
The undersigned requests and autlmdzes Pine View Cremak rium,In aa=danoe with snd subject to Its Rules and Regulations to
cremate the remains of:
Jessica Lynn (Wasmund) Weller F
(Flame) (mac)
8.2 Park Ave Fort Edward NY 12828-
(Sireet) (City) (fie) (ZJp tom)
vdto died on 15th day of March 20_
at Albany Medical Center Albany NY
(Place) (Address)
Name and address of nearest living relative or name of person autttortrinp cF m Wm:
Tyson Weller 82 Park Avenue
(Name) (Address)
Relationship to the deceased Husband
Name of Funeraltror. Carleton Funeral Home, Inc.
IMPORTANT:
I repreewl that to the beet of my krrvwladpe,the deaessad QW)4r(has no) ,detlbritle lar,battery,battery Imo,lie'
ceN,radioactive implant or ratiloactive device in his or her body.(
I certify that I how full power and aWwri¢aHon to arrange for the cremeSon of the remains and to d%W the disposition of the
cremated remains,that any personal possessions have either heen removed or may be desh%red,and agree to protect,defend and
save ham*=Pine View Crematorium tram any and all claims and demands for loss or damages wh+ctt may be made against them
by reason ofFoFcww"xPx1Aed the cremation of said remains as dkv*ed,whethersuclt claims ordemandsareorarenotwholly
r
68 Main Street, Hudson Falls, NY
(Address)
82 Park Avenue, Fort Edward, NY 12828
(Signature and Address of Relative or Legal Representative)
Signed on this date: 3
Disposkim of Cremated Remains
I hereby direct Pine View Cremakw1urn to dispose of the creffeled remains as follows"-
Mail to
Other arrangements-Please specify:
if pulver¢etion of cremated remains Is requested,check here XX
Revision:April 18,2007