Holl, William H. Pme View Cemetery $ Crematorium
Quaker RORrl
Queensbury, NY 12804
(518) 745-4477 or (5t11) 745-4476
FUNERAL ROME:
OgTE 8 TIME REM - - --- RETURN TIME.
REMAINS ARRIVED AT LRPMpiVRY: _ " -.__.._...
N"C OF FUNERAL OIAEC TOR ON REORIST 4�i1DO
EREO RESIDENT DELIVERING REMAINS;
NAME
TYPE OF CONTAINER VF -CASE X _. -_
PLACE OF DEATH: 74p-- -�
RMMf "_PN.e
ESTIMATED WEIGHT OF REMAINS B CONTA,INER //II
PLACED IN HOLD:
PLACED IN REFRIGERATION;
DATE OF _._ 3Jc_Itl.._._
CREMATION:
TIME STARTED;
- -TIME CO
PLACED IN RETORT
1.711 An
RETORT A IN WR I C R REMAINS WERE CREMATED;MOVED.. .""
DETAILED REASON FOR DELAY IFREMAIN5 WERE CREMATED R Np
FROM TIME OF ACCEPTED DELIVERY AN CR HOURS
NOTE. - .- .......
nTION LOG SHALL Y[ n -
Ei M[ pEllmqukNT 'RE OF THE Cn[mnrOpV,
IEWYi DIVISI0nof ON OFempaest.S
STE I ` MVISIOHa OFCEMElEp1Ee
OPPOIfNXITy. Cemeteries 9u WasNrglen<wnue
bry MY 122TnW1
iekpnone'.15181(266}26
Authorin lon for Cremation and Disposition
mis Autlgrha Form must So complebe and signed par b axhery off model brcw on.
Cale; 09/1712020 Nurnmr: 103y
Chamber Name Pine Vlew Canonical
Am 51 Quaker ROAD Qummburv, NY 128M Phaw'. 1618)]0.544TI
CREMATION IS AN IRREVERSIaLE AND FINAL PROCESS.
Crareason is mrfied out by placing Me remains of the eeseaeee and lye min iner holding the nmtlna am a cremat'v1 dumber wan
they are aubjecled Wmien»heat and name. That beat and Name will grommide and cammuma Wa ifte otaro age natal.
"fell am all that Will be left Allen rnmMbn.
Fcuowin9 diameter, Ire uemWmm Mu Into mem rrane afore to remove at of the ream and other mMenal from Ma aamAon
chamber but same minimal dust and words Sill likely be left berme. The mandatory will separate modemal and foreign nommi fiom
the remains and Melndeenml and foreign material all be diepobd of as rmulrcd by low. The aemattl Small wX be meMWf lly
puln"md imo small perms and placed into a compound comainerarum. CrwwtW mneim penenlly an Wlvelaed u"l m
Single fnpmam IS nCopniuble as ska lIisew.
OPENING OF THE CONTAINER
The crematory may only open the Wnteter holding Me talismans human remains in limited uwmMl ,such as to wnrimr the
Sidi Me damaged or to ensure that no mail Is dMbent which noting injure emplowas or damage the crematoy pmperby. X
human nmtlnsailielhmed maconainarwhichY nWBumble Iw Cr WnfuChas Cermwnlalornnnlcask4tat
remarory will repulnthattln renMlm ba movetl Inb a aunabla Canninen bebn X eeeapM tln nmalm. The mgand of a
Comeirer or Me venanr w remm'al of Smeins vnu W CorduMd pates a witness erne vAll bB sCnB In pnvary, Sung dpruN are respell.
IDENTIFICATON OF DECEASED
Namep recommend Wiliam H. Hall MMNI Sams: MXrtIe !
Lae Known Addmx:26 Bonner Drive, Queambury, NY 12804
time of Death. 2R Bonner Drive, Que buw, NY 12804
Eye: ® M OF Age: 82 Cog: 10111I107 pre dDmM: 09/1r12020 Emmetsd wAVm:L
Macripam mcnkeumntairor m wnbn mneim yell a daiiveme
PERSON N CONTROL OFOSPOSTON
rybmn(gllmm�Wl mmapod[mry �oxFd IlreroMxangl
I small are lye designated agent of Me demems eH WW,n a and or wirier Inanument emcNM Portual W Public
NWM LewS on 4201.
dl iM'e haw no knowledge Met May com
mand irnWnwm hall lc PUEul Hear etl ry n law svl Azar l
elncEOm her Me diapwmon of his or her remains ane IN.p am the customs)how, g peomys under Public lime Lew
sectlm emI all have Me rght to aWhnrize treatment of on minas W Me seuaeed. Myrour Mil whip to Nw elecenatl bAN
b1lm:
William H. Holl
DOE-18984(Rev. Ot Page 1 ill
Authorization for Cremation and Disposition
fors M1Omfho1i.4Cebw)
Number 2 Description. SWuee
arson designated in writing Pull to Public Heats law Sedbn 4201(3);
surviving "us
L. TR surviving b^mel peMer;
3. My wrviving chid eighteen years M age or deer;
4. AsuMNng parent
S. A euMWne sidling eighteen years M Poe or ltler;
6. Alawlully appointed guardian,
]. My amount common years Of age Or Older annual to share In p1e 691ak and whoieare maeet in reat'vuhir to MedNg9aW;
s. A duly centered Muciary of the aerate;
g. A clan Mend or relative she has executed a whips,statement pursuant to Food Health Law Setllm@01p);
10. Achlef 0auaal oMmr of a counts or a Whfc administrator apparel pursuant no the Sumgace'a C m Persona a Atl;
10s. Am other person sho is doing on Whole of the deceased and whe has eaeuMd a w nsWm t pursuant b bond Heats
new S Kenner 4201p)
FEE dllre Mode f IA
We Makey Wit end Me body of Me hceaud does red wrdam a battery, battery pe6, pmeer cell, reduaGive Implant
Or radioactive devim and that any such materials"m removal pm M Me eeecrt N this AUMdr/Hatlon Fdm¢ Felluse Me remM
u-52
e ' pAdminimalma r b minimal y ms ham us In ha to led cumal s constantly,Mr MMI.
cove affirm that Membrane haw been given te Weenndy MM.Bulch
regarding Me removal OI am personal pgMy,or purer thug W wore When Any person signing paWw or Any fmmiy nember of nM
deadedaimed M feel Pine View Crematorium
w.w.ra.w
Ia fql raepOnelbk brlM remwalMarsanal item¢M1om Me wribinaror M1om Me mmein¢al Me deoysee. Pma lX M 4n6
O nWM with the remains sell M MaV by tM commands
process and anentHRer amm Ca mail atlon.
9 Y
NW Nnby aut m Pine View Crematorium
ro.u�r to cnmsle Me remains of tlx dacaaead.
Auer OPTO,VAU
Use,Mn Momentum
by Mentum the named funnel director the W e prov ear delivery,to and channel by an eleme to
mm�ory, IFdeemed necessary In the opinion athe tenant director,and to aboard PB term In provlds Ma correct Memo and
address of such aMnate crematory.
FINAL INSP0611TION
Ta person numerical be emive this verMeled remalM atM dBaead term Me aemabry is
wmm'Singleton Sullivan Potter Funeral Home
Adtlreas; 407 Bay Road Ou hen6bury. NY 12W4 Inure (618) 798 69
The tramadd remains of tlaamal mil a diapcaN M as higher;
Bunal — Pine View Cemetery
If for Any mac^me Iswmn dmM]soon Mae not tMs p^nesNOn of Ma nennel nodded,
Pine View Crematorium is awrmnd te ens pcW¢mn of
newel
Mamm w Singleton Sullivan Fetter Funeral Home by ealexry
w+ cow
in pardon or by,regaeree mum. William H. Holt
o Iagacf(Rev. de201 Ppa 2 of
Authoriution for Cremation and Disposition
It mnpl
�� vax ummnna umune mnw�te.re nmGFlrted Wbiln lzp a.y.mcmmernn
Pine View Crematorium mgdepo.edNeremrnn
en inalienable matter, wish an my aulnrirg. nr.i.wcwat
E L
LW1/ONE W Me bAbwing)
M urn ro ma usud es a wMaiter Mtln umrgley mneiia tees mean WrmaM M1an
and a eeacnmwl as knows.
VrVe uMensend foal iltlp um eRaarrell m M1ON Ilgeritin uemale0 mmmhu,an ayamY iYgW canleircmay M iuetlkrdNFyry
OR
�/ M um is mtyN WrrfuesU. µye uMualaMNH tlm um b Wrdnevl wWmxka gwMW
Pine View Crematorium wra pace ties rmrrmflsIs
.wownr
a ryld brrpumry wmelnr for N wry.
This Amtndsaton von NO Podded y Wendy M. Busch wesew..neem
Singleltn Sullivan Potter Funernal Home
Ao] Bay RoaE, Dueenstur NV 1290A
Bred 6 viand y me tent s dower as winners to As execution. a�
IMe new scarves a cornoledol may of this Ammnmaun Fnrm.
thin perennial hionunMmelow blare thewreops)In Control of distinction,who try Ni this deforestation Few.Nestle)sediment and
r pWnns of tit Mmmntlon conned In tlnb Authenticated Form ON SUMNIma)W farespN9.
akted MY /11h need Seplembar ,rp 20 //Qr
Phyllis Hill
26 Bonner Drive, Dueendwry, NV 12804 �+
rmwvAww.,. mww
WBXFta: ( t ).Al d
�nWerdv M. Bulich " — J'C_r
ns,a 1p441
William H. Holt
owseese
0Q5-18984 Otani.0 11) Pape 3 of3