Pulling, Ruth S
(-rO W N OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director�j
Name u 't � '��t� t� � �Yr' Case #
Date cf Cremation `f _ —2—
Time Cremation Started �Lt�—
Time Cremation Completed 1�
Type of Container
Remarks :
J
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
Ho 5 daysays or weunday00
A.M. - 3:30 P.M. Monday-Friday. pre-arrangements by
arrangements can be made for Saturday.
telephone for acceptance of remains is necessary.
2. Pine View Crematorium is Townlocated ueensthe grounds of the Piffle
View Cemetery, Quaker Road,
3. An authorization for cremation 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
thedi have teitherf been remove
the crematemay remaibe
that any personal possessions
destroyed and agree to protect, defend and save harmless Pine View
Crematorium from any and all claims and demands
for or conne Of
damages which may be made against them by reason
ed
of said remains and/or disposition of said
with the cremation
remains as directed, whether such claims or demands are, or are
not wholly groundless, false orfra mustn . This authorization
accompanytheremainsIl ill
permit
addition to a regular bu udu
4 . All remains must be encased in a casket or suitable alternate
container. Caskets and containers must be of combustible
material. No Styrofoam or plastic containers will be accepted.
5. The question relative to rdiac pacemaers form Uefore the Iust be remains will rbe
ed
on the authorization to cremate
accepted.
6. Unless other arrangements Mail wit hi are mae the threeated remains will
days of cremation
be mailed via Registered U.S.
to the funeral home handling the service. There will be a $25.00
charge for this service.
Cremation, Administration Costs and Recording Fee: Adult $300.00
Children (age 13 months to 12 years) $150.00 Infants (stillborn
to 12 months) $100.00
* Additional $100.00 charge for cremations done after 3:00 P•M-
Monday through Friday. Cremations done on Saturdays will be
d after 3:30
charged the additional $100.00 Any remains ed an adreceivell $100.00.
P.M. Mon_Fri or Saturday will be charged
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 7454477(if no answer)
Cemetery 74544.76
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:
Ruth Madeline Pulling Female
(NAME) (SEX)
1 1
Horace Nye Nursing Home, Elizabethtown, New York 12932
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 25th day of October 20 04
at Horace Nye Nursing Home, -Elizabethtown, New York 12932
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
-4 -PL, Ir"e3 as 14. y .
)as(k3
Relationship to deceased S C) r)
Name of Funeral Home____Wilcox & Regan funeral home
Ticonderoga, New York
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 re not wholly groundless, false or fraudulent.
%1J h F� V/ c
( SS) y (ADDRESS)
0 (SIGNATURE OF RELATIVE EG REP.AND ADDRESS)
igned on this date: I !? may