MacCauley, Douglas To O
-7 QU r-E
?IN Y(EW CEM;�TE'RY ,� SB c_-L(I
ROAp ND CREMATORIUM
QVBrNS9URY, NEW YORK 12804
(518) 745.a476 (518) 745.•4-477
\ +Te Funeral Director
�C, ''II
K,--20� �5�� Casey
Crematf.on
Z 100
Te remation Started
�e CremaIIon Completed
Contalner
S f 011,E (A SF-
M s I( 3� �,
lZ'1G
Town of Queertsbttry
Pine View CemeWy and Crematorium
21 Choker Road.Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Authofization to Cremate
The urrdersigrred mqueets and ar*xxt m Pure view Crematorium,In scowdowe wkh arrd sabjed to ks Ruk a and Regtftiow to
cremate the remains at:
Douglas MacCauley M
(Name) (Sex)
Pleasant Greenwich NY 12834-
(Sbled) (W (State) (Zip Code)
vAv dad on dayd 04/21/2009 20_
at Glens Falls Hospital Glens Falls NY
(PIOM) ( )
Name and address d nearest living relat m or name of person authmzng cren ebm
Isabel MacCauley Pleasant Villa Tr
(Name) (Address)
RekffiorW*to1Wife
Nw o(Furemilknre Carleton Funeral Home, Inc.
IMPORTANT:
i repeserrt that to the best of my knaekdge,the deceased(has)Or(fras no)peammkw,deftrilafor,battery,battery peck.power
cK redioacam b.4ft t or radk*x ve device in his or her body.(Circe One)
i oadfy that I have M power and eutlrori¢etion ID arrange for the ctemedon of the remains and to direct the depoeitian of the
cremated rivim*s,that any pareorret poseaesknu have eNNN peen removed or may be deeboyed,wd agree to prated,defend and
save hertrtasa Pine view Cnwool rtren from arty aid ON claims and dearer Is for loss or damages which may be made agskidt them
by or Ow aemdion of add retridrrs as drected,whether arch daktta or denur ds are or ala not wholy
68 Main Street, Hudson Falls, NY
(V ftm) (Aftem)
Pleasant Villa
(Signature and Address of Re4aw�e7�oor Legal RepreowtaINe)
Sgned on Otis date: `�G��
Dbpwkim of Crenr ded Remains
I hereby dked Pure Vkw Cremebrkrm to dispose of the c nmw tad renv"as foNows-
Mom to
Other anvVernevft-Pbsee spedry_
if mdvvft on of awv tad remains m requested,dv&here XX
Revigirxt April 18,2007