Male, Ruth Funeral Director: M •13- C(ar K
Name of Deceased: Ruck
Case Number: 2 3
Date of Cremation:' L,' (, -U
Retort: 1.rA w f-v,d
Time Cremation Started: o 2
Time Cremation Completed: 3.
Type of Container:
Remarks:
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TOWN (f QUEENSBURY
PINE VIEW CEMETERY
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CREMATORIUM
Quaker Road, Queensbury, New York 12804
` Phone(518)Crematorium 745-4477(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:
Ruth Tolman Male Female. .
(NAME) t t (SEX)
420 Old Military Road, Lake Placid, NY 12946
(STREET) (CITY) (STATE) (ZIP CODE)
4th June 20 05
who died on day of
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iJihlein Mercy Center 420 Old Military Rd. , Lake Placid, NY
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(PLACE) (ADDRESS)
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Name and awes s of nearest living relative or name of person authorizing cremation:
Chary A�' •('n1 man 2901 Raven Rnan iJi i mi nqt nn n 1 A1�ii-n
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Relationship to deceased Son
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Name of Funeral Home
aMac Ave.
Lake Placid, NY 12946
IMPORTANT
I represent that to the best of my knowledge,the deceased as has n 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 re fraudulentss as directed,whether
such claims or demands are or are not wholly groundless,false or
2 310 S a.r a n a c Ave , Lake Placid, NY 12046 Gu�
TNESS) (ADDRESS)
d. wilmin ton, DE 19810
y �. 1 503 /aven R g
n
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS) •
Signed on this date:
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DISPOSITION OF CREMATED "INS
I hereby direct Pine View Crematori remains as follows: um to dispose of the cremated
116.$1. alat*. 2--
VUL
Mail to 2310 Saranac Aviv
Other arrangements - ple ase spec ify:
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.
o Holidays or Sundays,
arrangements can be made for aturda
telephone for acceptance of remains is necessary.*
arrangements by
2. Pine View Crematorium is located on the grounds of the Pine
View Cemetery, Quaker Road, Town of Queensbury.
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 lass of
damages which may be made against them by reason of or c cted
with the cremation of said remains and/or disposition o said
remains as directed, whether such claims or demands ark, or are
not wholly groundless, false or fraudulent. This authorization in
addition to a regular burial permit must accompany the remains.
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 cardiac pacemakers must be answered
on the authorization to cremate form before the remains will be
accepted.
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 $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
charged the additional $100. 00 Any remains received after 3:30
P.M. Mon-Fri or Saturday will be charged an additional $100.00.