Macey, Lawrence OF QUEE9,�593U ,�
PLN
E �qEW CEMETERY AND CREMATORIUM
QUAKFR ROAD, QUEENSSURY i�'W YORK 12804
(518) 745.4476 (518) 745-4-477
Funeral Director j
Name 6 l�
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Cased 1�
Dace OF Cremation
T :me Cremation Started gIUG _
T , me Cremation Completed
Type c ; Container
�emarKS
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Town of Queet:tsbury
Pine View Cemelmy and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Audxmization to Cremate
The w dsrslpned requests and att wtzes Plne view Crematorium,in a000rdertoe with wit sullied to tts Rules and Rog,lations to
cremate ttte remains of:
Lawrence Cecil Macey M
(Flame) (Sex)
4.639 Lake Shore m2ihtaon Landing NY 12814
( ) (City) Owe) (Zip Code)
nitro died on day of 01/3 0/2 0 0 8 20_
at Glens Falls Hospital Glens Falls NY
( ) (AAdrem)
Name and address Of nearest Uvkrp nola a or name of person autt flan c eamtiort:
Kathy Nolan 4 Brenda Drive, Hudson Falls, NY
(Name) (Address)
ReisRi Mftt0"deCWSWdaughter
Nanteof Funeral tim. Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the beet of my knowledge,the de0e60ed(fiss)or(hen rto)Peoenreker,deftdkW,beltery,bvt wy Pam,Power
cep,radaecd"k Tq tent or nugoacrive device in his or her body.(C kde One)
i 0W*that i have U power and suftto undon to arrange for the cmmu don of the renmIns and to direct the dispoeidan of the
cremated Tweirts,that any pemanall pew have eN WN been removed or may be deearoyed,and agree to proleGL defend and
am hams w Ptne New Crooabriuert from any and ark ck ms aid derrtentds tidy bee or dwntages whidt may be ntad apdntat dram
by reason of or cortrtecW wNh the cremadon of said remelts W dkW9d,wh6dW arch halms or di o ds ere or ere not wholy
groundless,tales or
68 Main Street, Hudson Falls, NY
(Address)
� 4 Brenda Drive, Hudson Falls, NY
�. ,
of Relative or�.egek RePreeeMadlve)
Signed on this date: 3 00�5
Dispwbm of Cremated Rerrtalov
I hereby dire«Mine View{Yemedor M to dispose of the 0ernated remelts ae idiows'.
Maki to
Other arrartgarnerm-Pleeas specUy:
If pulw&Mion of Cremated remains is requested,check here XX
RevWon:ApdI 18,2007