Hall, Janice rrnrmlN OF,:,
5B UJ
PWE 'VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12844
(518) 745-4476 (518) 745-4477
Funeral Director
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Name �
Case q
Date of Cremation
Time Cremation Started q,30 A
Time Cremation Completed 3s
Type of Container � pw„C-
Remarks :
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Town of Queerisbury
Pine View CemetM and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477 '
Authorization to Cremate
The urrderslgned requests and au#wrtaes Pine View Crernetarlum.in accordance vrlth and w*d to Its Rubs and Regulations to
cmrme the remains or:
Janice Ruth Hall Female
(Noma) {Seoc)
Fort Hudson HCF Fort Edward NY 12828
(Street) (CRY) (State) (vp code)
%ft died on 19th ftd November 2009
at FORT HUDSON HEALTH CARE FACFort Edward NY
(PIKS) (► )
Name and address of nearest lW g reh*m or name of pemn audwrtAV cronm m
(Name) )
RelatiOn9lip 1
0 the ftM9ed S on
Named Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
l represent that to the beat of fry knowledg%the deceased �OrnD) ,defibrt�artor,battery,battery pace,power
call,radioactive k;ftl or n0oa�ve devise In his ar her body.
1 ow*that i have Thdi power and nuftwb tIon eo arrange for the cranredon of Ure nsrnahs end to dWW the disposition of the
cremated ramakhs,Ural any personal poseessions have eitrher been removed or may be desk%-ed,and agree to protect,defend and
save henrilm Pine View from wV and all claims and dwwKis for ices or damages which may be made eg*wt them
by c0nrhecled uemoon of add mmeins as dkeded,whether much dab,rs or rip raeerde are or are not wholly
or
68 Main Street, Hudson Falls, NY
lf""— 0 vvia-n)- 0— 4 V�V
(Sonatum and Address of Relative or Legal Representative)
Signed on this date: 1 t Z
Disposition of Cremated Remains
l hereby direct Pine View Crematorkhm to diapaee of the crefreted remekrs 99 tollaw8:.
mail to
other arrangemer t-Please epeelry:
if pAmbation of cremated ruins is requested,check here XX
Revision:Aprh 18,2007