Gaillardet, Lionel rr0 WN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name 1'-) 1 d h,lf el� 11 ��- I��W^ Arse # 161
1
Date of Cremation � - ;)-9 0
Time Cremation Started O (�0r
Time Cremation Completed / 5 %or m /
Type of Container cA�'je. Q- �j . �'/
Remarks :
M A- i
l� ' Q
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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:
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on f S day of / 20a //s
AVI
(PLACE) (A RESS)
Name and address of nearest living relative or name of person authorizing cremation:
rs C2—
Relationship to deceased
Name of Funeral Home
C j^ C Lout KM A)
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
agai hem by rea or connected with the cremation of said remains as directed, whether
suc c ms or de r r re not wholly ndle s, false or fraudulent'
JT�
A4
4NS) (ADDRESS)OF R ATI E OR LEGAL P. N ADDRESS)
Signed on this date:
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium
dispose of the cremated remains as follows:
Mail to t ` �
r
Other arrangements-please specify:
If pulverization of cremated 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 P1,1. 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 or 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. 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 $20.00 charge for this service.
Cremation, Administration Costs and Recording Fee: Adult$225.00 Children (age 13 months to
12 years)$115.00 Infants (stillborn to 12 months) $75.00
" Additional $50.00 charge for cremations done after 3:00 P.M. Monday through Friday.
Cremations done on Saturdays will be charged the additional $50.00.
�Y6
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lionel H Gaillardet Male
Date of Death Age If Veteran of U.S. Armed Forces,
04/01/2000 78 years War or Dates
Place of Death Hospital, Institution or
City, Town or Village City Of Glens Falls Street Address Glens Falls Hospital
Manner of Death[�,Katural Cause Accident Homicide ❑Suicide Undetermined Pending
Circumstances Investigation
Medical Certifier Name Title
Daniel Way M. D.
Address
North Creek Health Center North Creek, N Y 12853
Death Certificate Filed District Number Register Number
City, Town or Village City Of Glens Falls 5801 189
Date Cemetery or Crematory
ElBurial 04/03/2000 Pine View Crematorium
Address
Cremation Queensbury, NY 12804
Date Place Removed
❑Removal and/or Held
and/or Address
HDId
Q Date Point of
Transportation Shipment
by Common Destination
Carrier
Disinterment Date Cemetery Address
Reinterment Date Cemetery Address
'> Permit Issued to Registration Number
Name of Funeral Home Edward L. Kelly funeral Home 00557
Address
Schroon Lake, NY 12870
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
110.
Permission is hereby granted to dispose of the human remains described a ove s in t d.
Date Issued 04/03/2000 Registrar of Vital Statistics
(signature)
District Number 5601 Place City Of Glens Falls
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
g Date of Disposition Place of Disposition PI
(address)
Uj
(section) (lot number) (grave number)
0 Name of Sexton or Person in Charge of Premises M 1 C`1 q -ej
(per a print)
Signature Title r re� Toc*�! !S5j"T--_
(over)
DOH-1555 (9/98)