Hall, Ruth T- O- WN OF UEE BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorC`/ /f1 /1C
Name 9111d ��'J,�1� Case # (7
Date of Cremat i crnAo
Time Cremation Started Ve
Time Cremation Completed M f qe AM
Type of Container (i oeM -D ou a r eAsoe- ®'/C 7—,o " ,r J
Remarks :
90/W i9r-9 0,4IK6 9 43 IV A IAI?
r
��o ? idM
tow" OF t3uttNstlUttY �Tl
aINE VI�N CEMEIEftY
ttiEMht[lR l UM
Quakhr Road, Quetihibury, NPW York 12804
Phone (518) CremAtorioA 745-4477 or if no answer
Cemetbry 145-4476
AUtt(oftlZnttUN tU CREMATE
The uhdersigned request 's And authoriies Pine View Crematorium, in
accorrdahce with And sub,j@ct tti itt "010s and Regulations to
cremate the rOMA ins of:
Ruth Potter Hall Female - --
(Name) (Sept)
Indinn Riue�r Nursing Home Granville, NY
(Street ) (City) (Statb) (Zip Code )
who d i ed on ? h day Of July 19 _96
At Glens s• i t Helapital 100 Park Street Glens FaIIR NY 128t]1
(Place) (Addre43)
Name and addr#94 of hbare►4t living rrlativ# or name of person
authbl^i2ing Cr0MAtibh !
JMr. Jon R. Hall RD 2
(Nalne) (Addre40
Relatiohthip to thb det_@444d Son
No*# of l=unera), Homi;
I MPUM ONT!
went that to tho best of my knowledge, thb deceased has or:
has )ib pace*aker ih H4 br hrr bbdVa (circle One)
1 certify than 1 hav6 thb full poNtir and authbri2atioh to arrange
for the crfmdtibn of the retnain4 and to direct the disposition of
the cv-#Mated reaAihst thAt ahy 0eh3bhal pt4g64sions havb either
bebh reAovbd or mAy by dpbtrbyedt And agreb to protbct, defend
and 4ave har*1@49 Pint, VibW CrOMAttrium front any and all claims
and domand3 for loss or dam69e4 which may be made against them by
r@Atkov of or cbhn@ctbd with th# tr@nlatibn of ;aid remains as
direr ed, whether Ouch t14144 or dembadg arf or are+ not wholly
gro le4e, also or fraUdUl§nt.
61 S-�
;92ign!!*��tur@of
ets> (nddrets) t 2 P-31
Relative br Legal Rbp. and Address)
Signed on thi4 datbt � I�I �
b I SPUS I t I UN OF Cl2EMt11 EU ltrMn[NS
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 ---'
PUL I C i ES, "ULI=S f1NU "EGULA t I UNS
1 . The crematorium will be open for cremations S days a was,if
7 :00 A.M. - 3: 30 P.H. Monday-Friday. No Ho idays or Sunday,
arrangements can be made for Saturday. Prearrangements r ,
telephone for acceptance of remains is necessary.
2. Pine View Crematorium is located on the grounds of the Pins,
View Cemetery# Quaker Iload# Town of Oueensbury.
3. An authorization for cremation properly signed by the nearest
neat of kin or other authorized person stating that they do hays,
the power and authority to arrange for the cremation of thr,
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 Pitts,
View Crematorium from any and all claims and demands for loss of
damages which may be made against them by reason of or connect l
with the cremation of sAid remains and/or disposition of sera#
remains as directed, whether such Claims or demands are, or errs,
not wholly groundless# false or fraudulent. This authoriz�� �
in addition to a regular burial permit must accompany tli�
remains.
4. All remains must be encased in a casket or suitable alternate
container. Caskets and containers most be of combustible
6aterial . No styrAfoam or plastic containers will be accepted.
S. Tho question relative to cardiac pacemakers must be ans%,-,
on the Authorization to Cremate form before the remains will hi-
accept ed.
6. Unless other arrangements are made the cremated remains will
be mailed via Registered U. S. Mail within three days of cremation
to the funerAl home handling the service. There will be a $20. 00
charge for thi s set-vice.
Cremation, Administration Costs and Recording Fee : Adult i175. 00
Children (Age 13 months to 12 years ) i100. 00 infants ( stillborn
to 12 months ) t60. 00