Hall, Thomas W. L O I'N OF QUEEVBU—WY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directory 1 s 0
Name 1 IA J +4A I Case #�
Date of Cremation f6 IL ( J
Time Cremation Started - ZV
Time Cremation Completed ) C�, ` ��� j 30
Type of Container 'Xka � 'Lcr` �✓r'"1!`7 �r��C' �' �Y
Remarks:
L2t41'N
!� f l � � I U (�✓vl
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to
Other arrangements - please specify :
If pulverization of cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
1 . The crematorium will be open for cremations 5 days a week
7:00 A. M. - 3 : 30 P. M. Monday-Friday. No Holidays or Sundays,
arrangements can be made f r- Saturday. Prearrangements by
telephone for acceptance of re.{iains is necessary.
2. Pine View Crematorium is located on the grounds of the Pine
View Cemetery, Quaker Road, To�_i of Queensbury.
3. An authorization for cremU. . oi, properly signed by the nearest
next of kin or other authorized person stating that they do have
the power and authority to arrange for the cremation of the
remains and to direct the uis sition of the cremated remains,
that any personal possessions gave either been removed or may be
destroyed and agree to protecc , defend and save harmless Pine
View Crematorium from any anc, claims and demands for loss of
damages which may be made aga : + , t them by reason of or connected
with the cremation of said rt, ,,_ , ns and/or disposition of said
remains as directed, whether s ..Li, claims or demands are, or are
not wholly groundless, false of fraudulent. This authorization
in addition to a regular burial permit must accompany the
remains.
4. All remains must be encasec. : i, a casket or suitable alternate
container. Caskets and cc:r. . - . ners must be of combustible
material . No styrafoam or plas-. . c containers will be accepted.
5. The question relative to crciac pacemakers must be answered
on the authorization to crematt.: form before the remains will be
accepted.
6. Unless other arrangements ..r- made the cremated remains will
be mailed via Registered U. S. Mail within three days of cremation
to the funeral home handling t:,i ervice. There will be a $20. 00
charge for this service.
Cremation, Administration Costs ;.d Recording Fee : Adult $ 185. 00
Children (age 13 months tc "rs ) $ 110. 00 Infants ( stillborn
to 12 months ) $70. 00
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
9
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of :
Thomas W. Hall Male
(Name ) (Sex)
RD2 Box 2652 Whitehall NY. 12887
(Street ) (City ) (State ) ( Zip Code)
who died on 8th day of Oct. 19 95
at Glens Falls Hospital
(Place) (Address )
Name and address of nearest living relative or name of person
authorizing cremation :
Priscilla Hall RD 2 Box 2652 Whitehall NY. 12887
(Name) (Address)
Relationship to the deceased Wife
Jillson Funeral Home Inc.
Nave of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange
for the cremation of the remains and to direct the disposition of
the cremated remains, that any personal possessions have either
been removed or may be destroyed, and agree to protect, defend
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them by
reason of or. connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
(Wi ss ) (Address)
'1.
Signature f Re a ive or Legal Rep. and Address)
Signed on this date :