Scally, Lawrence L O q4N OF QUEEVBU—IKY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C:, " vz1—C'A-y (�:L
Name Afa ') lqLK% se"V4 /-I- k Case#
Date Of Cremation
Time Cremation Started T1 � o y
Time Cremation Completed ��-
Type of Container asW�
Remarks }�
y 3 1q:: 1
C2
i D 5-5 t^:yA
Town of Queensbury
Pine view Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)7454476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and suthortzes Pins View Crematorium,in accordernce with and subject to Its Ruiers and Regulations to
cremate the remains of:
Lawrence C. Scally M
(Nam) _._ _�� (SOX)
Indian River RehabG&ahudl$h Care NY 12832-
(Stres!) 03/27/2006 PIP (Sk") (Zip Code)
who died on dayof
Glens Falls ospi a ens Falls ---�"—'
at
(ems) (Address)
Name and address a neerset Nving nsWve or rwms of person au*mdzIrq cremation:
Mrs. Viola Scally Indian River Rehab & Health Care
(torte) (Address)
Reloknsho to to deceased Wife
Name of Fr wngHame Carleton Funeral Home, Inc.
tMPORTANT:
I represent that to the best of my bmwledge,the deceased(has)or(has no)pacemaker,deft 0alor or any other bWkVy operated
device in his or her body. (Ci cis One)
car*that I have full power and a ft rizz4on to arrange for the cremaion of the rernsins and to direct the disposition of the
cremated remains,that any p g g g i1possessions have either been removed or may be deshoyed,and agree to pralxt,defend and
am harmless Pine View Cnwmk ium Mom any and aN clakns and rim I d3 for ions or damages vtdch may be nneft easkid them
byiesm of or cornrnecled with aarrrelion of said rernairns as directed,whadw such claims or demands are ar are not>wrh*
"XdO7��- ee '�/1141015"" 61';!�////'
(vifbess) (Address)
(SWisture and Address of 9gal Reprsaeradve)
Signed on tits date: �/'�7,1? t,
OrsposWM of Cremated Remains
1 hereby direct PMe View Cremstorium to dispose of the cren*fto remains as fo*-s:
MON to
Odw errengernernts-Pleeae apeW. _
If MOvermatim of cremated remains is requested,dnedc here XX
Revision:January 1,2006