Wadsworth, Clark D. Pine View Cemetery g Crem
atorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 Or (518) 748-4476
FUNERAL HOME: ____
___.4"fRR'TPeW..
-- RETURN TIME __ _
OATS 8 TIME REMAINS ARRIVED AT CREMATORY; _ y—p- -
NAME OF FUNERAL DIRECTOR OR RECRISTCREO RESIDENT DELIVERING REMAINS,
nn✓ HOCt�I __..________- ___ ---
NAME: _
TYPE OF CONTAINER: /DX
/I
1 CASE # "'"--
OF DEATH. I Nov
I1gE� all-
PLACE WNy _ j
_. fir --"—Art I fµ—_46ntj:,� Igt6
ESTIMATED WEIGHT OF REMAINS 6 CONTAINER .IjA
PLACED IN HOLD:
PLACED IN REFRIGERATION:
740
OATS OF CREMATION: _ _ 1q/��II�I� '-'---
TIME STARTED: - -_7 5O/ yl�[yam D: ...-
T mE C
ED:
PLACED IN RETOft __ b
T. �,L(Q/)♦� - --'
RETORT II IN WHICH REMAINS WERE CREMATED; _
DETAILED REASON FOR DELAY IF REMAINS WERE CREMAT-AAMpRE TpHAN�4S HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE. THE CREMATION REMATO O - - R Z T41NEO
Ni osuw
sNEWYORK �IVISIOfI Of DIVISION
9Orl ...r.RIM
L STTT O Ca
Cemeteries
rt NY 12231 AM
wrom s'lete,aMods
Authorization for Cremation and Disposition
This AUM a0 Foml in ust be compNad and sig red prior to abed y a remalnle'for cmma4om.
OM'. EBO32020 Number
cremalw Name: Mmv Clemabry
Morris, 21 Omer Ford,OueerrsdVY. NY tza'JO I. Mp. I51e1 74SMn
CREMATION IB AN IRREVEMME AND FiN PROCESS.
CremeM1on Is carved our of pl%irg they remain co rho dewal and they mnbirer holding the remains may a mail cMmWrx m
they are subjected tonsured heMand Fame. The heat aM same All mamrate and consume everything ancem bone and met
which an all thatwlll be IM aMren U".
Fouomng crenummin Me crematory MII bk0 maWnede erbrB to rumors all other remains and other marmal horn Me wma0on
chamber but same minimal dust and residua Mil Likely has left behind The local MII xparab Incidental am breign mabdal M1om
remainson am the alll and breign materiel will m disposed stay required by law. The Term and annual wmx m"IN
puiverl Ind email gOWe also pla¢M Imo a deal9nabl Decorator um. Cnmabd remains generally am puiveb wall no
single fragment 4 recognizable as abbtal xwue.
OPENING OF THE COMA NER
The oxmaml may only men 00 wntvmr holding the unrremabd human remains in limited Grcumatances, such as to comml they
ihuman omfmaW am Ina w=lnerwhlch
Nntm nWclm auedlabble kri 9mMmalutlraene suchmpclh as
maomnaaael or c Tl casly pmp
emw *11 require
Met
M remains
My Named
Into a MINIMAL
onabmtbNmIte he hundins. TMmnsi aOf
a
container ofthe transfer or mutual of remaMuA a mMuded bekn a MNeas eM we ma When pi witll dgirr mid
x
respell
IDENTIFICATION OF OECEAEED
Name of@was00: Clark D.Wed M MAMl ysuly., Din
leer Known Amems'. 619 Rhw ROW, Wrhi NY 121M
Place M Death. 2 2ugrym AN, Fort EAVW, NY 12M8
sea: [am OF Age: 82 Doe. 11/18/1937 o am o9w m EegnaW WNa=
Dempdon of wkevmnbinw,n Midi ranam AM as refial.
Cardboard Box wNJooden Base
PERSON IN CONTROL OF DISPOSITION
rPonoMs)In coned a aepoainm,mom ONE or ma ktbwYmTl
I andi are m designated agent of Mal daxaxd dedgnmd In a will or w nimhummluOCUW pumrat to Public
/HQame,\,W Suter 4MI
/$' �IAW hevx m kmwbdp0 Nat may doddered mMubd a wnMn instrument pwwanld Public XeaM Law season 4301 Or e
sW10TMHInmg handdsoe he me dNgsltlan o his or her remains and Islas an the m'mn(s)having Priority under Public I Mlow
S on 4201 and haw has rgM W aWraize awnarion of he mmvm a de demaeed. Whorl rebnoneM1lp to he dx WIs as
hibw:
Clark D. Wadsworth
DOS fIlyl Per 011 Pp01 of 3
Authorization for Cremation and Disposition
Ora Nunber ttr 3 De ml Dideawl
eMP00n'. BmM WeMvmim lDeWlrmrl
1. Ammon temporal in Mine pursuant to Ful NmM lax Samer a301131;
1. The survMrq seduce
}a. lM¢uMvinB domeshc pabwr;
> My survn'InB CNp normal year,of%a 0r Older
A Aeunil parent
S. A sul iolirg"hmen years of We or older. i
S. Al Mllyap% 19uamian:
]. Arry parainouWhaenyears OF age or 0ltler entitled m choose the exert and wiw Were clOaw[in model m the oewased,
S. A duly apmmMed fiduciary of my,e¢bbl
S. A men MaM Or relalwe who has emended a woman statement payment m Public NBBM Law Senior,4201(7)
10. AMiul fisal afiwr of awumy or a pane Administrator appointed rynOert to On Monc;, e's Court PmGtlNa AR
for. My power mean who to nor no an ba ll M ma Museum and who man executed a w n Moment 0urmant to Public Nealm
taw 5ealon 4201(7).
(Incedy ALL PIREE dine Memory
IM4 dKKehy seem that the body of Me demand doe3 now OMum a naXen, Oaticy Wck. 'power all.radloaccom import
prradioeNve devla aM eel any¢uN mabriaPoxwB remodel pdamtlwexembndNOANhoNNon Form. FailuMO emove
Nsse Items price cremation wry remh In hams toMe mandatory and cM1msmry grwnml.
�IAlb&arm mM inMwmens have dean givenm Rdiaq G. Hung
regarding owe ramavel of any personal pmpehy or of and Awrom which ary person spend nNOw Or any fmiry member M Vw
decimal manes to gemrve. Pire Nan Cremday
ie ndresponallila mane removal dldeiwnel lceme now MaaonUirerO:xo-n aldB remains duw deaeaed. Parson.I lees Nn In Me
mn�hNlner in with the remain$will ne dae4oyed q Me crwMtlon pro m am amend he removM after mediine
y We hor $Who me Pra UCremdory
canwhi
for cremate they remalm of MoMissouri
I�OPTIONM)
LMe homey authonae Me rumod funeral dimd to provltlo for Alelvery to and cremation by an amend,
trades".M Amend necessary in tlN opinion Of Me Nmmi 41MWr.and to amend Mo forme amend Me correct name and
&dome d such alomsb cMmamry.
FINAL gBPoSITON
The pinatasummit to hormone con common mein of Me mmond from May Gemium ,Is:
Name: Commemorate Furard Grin
Morris OM Mapo Add SeleMy Sdmigs of 12aM phoe. (51m5ml
The co maed remans of demaed will of d4 Of an
RMM TO FAMLY
If for aM reanon the perem named amour dcm he and puaeaaen Of Macemabf lanaim
mmv cmmq is aW mfarm aueeaNn of
M.melnm m..ael (pnpsmbmN Plead core, ma o-y adr«y
w
in person or mpooretl Mao. m�wwdw� Clark D.NYdrvnM
Authorization for Cremation and Disposition
Me demand)
IMb understand that(the remains are rat claimed xMm uo days cfcrema ion
pre View Creamery may,disease W the remains In
animbini manner.such as q waymm; lmmcemmn
CREMAi CONTAINEWRN
(mil ONE atlre We")
An um to be usee As a consumer M tM charmed reader has bean Seemed Than
and is Miami as moms:
IN@ understand Mn X Aa um b tin Amid b hold the mMra cremated remains,an Mditmal!qtl com ever may M used he d&Rery.
M um is rrotyrt Wrchaeb. INA understand Mal if mum q Ourthned ormMmve pavked
Pre,Yew Crematory, will [Ya9 Me,nBmaM remeinam
a h81d tanporary demands for daliuery
.
This AutlraN[atlon Form was trimmed b/ Rdlaad G Hi wabevstired at
Compassionate Funeral Ga, Inc
4W Meek AW SeatoJa Stsi NY 118(
and k vaned by has Nreral it ri as Maness k N aKKsmnmvnmew
IAVe have seemed a min plead say of this AuNwhatlm Fonn
The Ixmonls)Identiled hNow years Ms par ia)in control of impasNm,xTo Ey alarming She AutlrosUNon Farm,aMN(a)
he Me acwnry and cmmpkbns"MMs Inloymatlan coneelned In Nis AUMw(i1Yeu Form and alMomat Me fa m enp.
Signed!MY day of September at
&aMy VJedawoM
3 Buryoyne Rve., Fort EdmN, NY 1MB
spot um.wn &a i
WITNESS: / ��ii..ryry
ilex
China D.WalsxwN
OOB1e98-t)Re , BARB) Fa9e 3 M9