Hallock, Rose Marie TOWN OF QUEENSBURY
Piste Virtu Cemetery and Crematonurn
21 Quaker Road, Queensbury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
http //w\v-\v queensbury net
Funeral Director:
Name of Deceased: y 'A l�Li 'H W 1.�C?C"
Case Number:
Date of Cremation: 2Q aS�
Retort: �?
Time Cremation Started: (� �-
Time Cremation Completed: ea— 6 1"2 �-
Type of Container:
Remarks:
2 �-
i
Z -�5✓��, i
PAI
i
Howe o; NntulnI Ben itty ... A 000It PInie to Ltue
w
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the
remains as follows:
Mail to ^— ------ - -
Oiher arrangements - please specify: - - ---
If pulverization of cremate remains is requested, check here__
POLICIES, RULES AND REGULATIONS
1 . The crematorium will be ope ffor cremations 5 days a 'week 7 : 00
A.M. - 3:30 P.M. Monday .F y No Holidays or Sundays,
arrangements car. be made for
S to necessarye*arrangements by
telephone for acceptance of remains
2. Pine View Crematoria T located
o a Queensthe grounds of the Pine
View Cemetery, Quaker Road, o
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 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 of
damages which may be made against them by reason of or connected
with the cremation of said remains and/or disposition of said
remains as directed, whether such claims or demands are, or are
t. This
not wholly groundless,regular burial permit mustnaccompanyath eorenains. ill
addition to a regular
4 . All remains must be encased in a casket or suitable alternate
container. Caskets and containers must be of combustible
material. No StyrDfoam or plastic containers will be accepted.
5. The question relative to cardiac
form before the 1ust be remains will rbe
ed
on the authorization to cremate
accepted.
6. Unless other arrangements I are made the cremated remains will
Mal Within
be mailed via Registered U.S. ice. tTheredays willobecmation ae$25.00
hree
to the funeral home handling
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 Y.M.
Cremations done on Saturdays will be
Monday through Friday..
charged the additional $100.00 Any remains received after 3: 30 p.M. Mon-Fri or Saturday will be charged an additional $100.00.
i
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.
Rose Marie Hallock Female
(NAME) (SEX)
3 Park Avenue Ticonderoga, New York 12883
(STREET) (CITY ) (STATE) (ZIP CODE)
who died on 3rd day of February 20 05
at 3 Park Avenue, Ticonderoga, New York 12883
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Thomas Holman, 3 Park Avenue, Ticonderoga, New York 12883
Relationship to deceased__ son
Name of Funeral Nome Wilcox & Regan Funeral Home
IMPORTANT
I represent that to the hest of my knowledge, the deceased )as or 112sm 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
,C ma(odum 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.
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: 1:9 7-- C�