Gallant, Mary TOWN of QUEENs5BU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director u
Name g 7 C_j}// Case # /Q®
Date of Cremation y\ — U\ y
Time Cremation Started /0 r `7 �5_ 119_` l
Time Cremation Completed C00 P� "
Type of Container W00 C A-S 14C4- CRS^eld0" Thep/_V
Remarks :
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TOWN OF GUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or 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:
Mary Clare Gallant Female
(Name) (Sex)
2 Meadow Lane Saratoga Springs, New York, 12866
(Street ) (City) (State) (Zip Code)
who died on 16 day of February 19 98
at Florida Hospital Watermay, City of Eustis
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Lydia Moss 521 North Creek RdGreenfield, NY, 12833
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Burke Funeral Home
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 or are not wholly
groundless, false or fraudulent.
628 North Broadway, SS, NY, 12866
( ness) (Address)
I
521 North Creek Rd, Greenfield, NY, 12833
(Signature of Relative or Legal Rep. and Address)
I
Signed on this date : ����
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to Burke Funeral Home will pick up
Other arrangements - please specify :
If pulverization of cremate remains is requested, check here xxx
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. No Holidays or Sundays,
arrangements can be made for Saturday. Prearrangements by
telephone for acceptance of remains is necessary.
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 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
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. Nt- s'- yrafoam 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 f1S. 00
charge for this service.
Cremation, Administration Costs and Recording Fee : Adult $155. 00
Children (age 13 months to 12 years) $90. 0O Infants (stillborn
to 12 months) $50. 00
HAMLIN_&_HILBISH_FU,NPL TEL No .904-483-3094 Feb 18 ,SS 17 :37 No .004 P .02
1'ILY ib/�1. r.AMVI1I`CCKZP vrriIc 0 _%)L 5W 0436 02/18/98 16:27 b :01/01 N0:247
OFFICE-OF THE FIFTH DISTRICT MEDICAL EXAMINER
WIT1UCT TATE OF FLOMDA
C+TaUS.HE ICE•MARIDN•SUMTER COUNTW$
4W-A EAST DIXIE AVENUE
LEEISLAO,FLORIDA 34741
93621321•5961
Is6�y asb•su�rAx
DISTRICT MEDICAL IXAMINER ASSOCIATE MEDICAL EXAAghlEA
vNLLIAM H $wUTZE.M.b IUSAM M.RENDON,M D
LANRA I{.WUR,M.O.
ROSS C.WHEELER,M.D
►ATA CK OMLL,M.O
NO' 0070Z
VERBAL_ CKEMATLON AUTHORIZATION
DECEASED NAME. KID T --l `Xt_ (,a- (]4-DATE OF DEATH,_
FUNERAL HOME: �. ''1� M-- 14 PEE: _
DATE/TIME OF REQUEST _Q ! _! �QI BY: (/)I�FAX ! f PHONE
QEATFI INFORMATION
AGE- ir•%--- RACE: U.)- SEX,
PLACE OF DEATH. ; ) RESIDENCE ( ) NURSING HOME ( ) OTHER
ADDRESS:
(_j r4OSPITAL, (�41VIEROENCY ROOM, ( ) IN-PATIENT
NAME OF FACILITY ___�,,�� C�_V-Q.�l.�Y�•U'�_
1 r
COUNTY OF DEATH. J. '
CAUSE OF OE �H INFORMATION:
PART 1' A:
PART it
MANNER OF DEATH:_ \ � ����1 C�i•' INTERVAL
.
PHYSICIAN SIGNING DEATH CERTIFICATE: 1C4•17
r-r�
CREMATION APPROVAL OWEN: ES I ( f NO BY: , f . 1,Scan C.t-nd an
O.K.TO CREMATE PER. L.E A.; PER:
COPY OF DEATH-CERTIFICATE RECEIVED BY: ( } FAX ( ) DELPARY ( ) MAIL
DATE:I
�. ' -9 TIME: (t, 30 T)
AUTH.S OWEN TO: NAME: C)J�ea) ` ,_)