Scally Jr., Charles David Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: _—�___el�[ _ _ _ _ RETURN TIME:
DATE E TIME REMAINS ARRIVED AT CREMATORY: _ 7i2L Bp
NAME OF FUNERAL DIRECTOR OR REGRIETERED RESIDENT DELIVERING REMAINS:
—_—. hrrua� bt4+RLi
NAME:
TYPE OF CONTAINER: FGN(A N I rr
Place of Deem, �'ills
/M
ESTIMATED WEIGHT OF REMAINS E CONTAINER_ JYIJ
PLACED IN HOLD:
PLACED IN REFRIGERATION: b �
DATE OF CREMATION: _ q TIME STARTED: _ 'I.}Q{m TIME COMPLETED:
G _ II'AafU 1
PLACED IN RETORT: __ 1; BO MOVED:
RETORT A IN WHICH REMAINS WERE CREMATED: SWta FvjL
rau
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE: THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Now
NEW YORK co�amennt York
Some
3yJlECf UivtsiDn Dl ONIEMN OF CEMETERIEE
°° CemeteriesOrion CIrroor"Run
Affirlon,Nsn231hinal
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Authorization for Cremation and Disposition
This 1Ygpr4ryon FOTI mug now co Pl eland Sip pbr m"Sam of remains for cnTJgon.
him Jul 17.1020 Nunber 146
Cmmmrry Nam'. Pine Mm Cre mq
AEOiess 21 Quaker ROM, Oue &ury,NY Issue Phone, 318-742l
CRE MN 18 M IRRQVERS1 MD FINK.PROCESS.
Creme is maned Of 4 plaang the remains of Ne dammed and the mnminer milling the remaimmoon a cremat'mn TwWrv.Mre
they are auG6W tissues,hem and flame. The heat and name will IneW4b and consume everylhinS except hone and math
wh 10 fire fill had MII I w Ins Offer mmmlon.
Follmn aemsfwn, the monetary coma Wife reasonade Mbd¢to remove ell of TO remains also other material hom the cremation
chair but Som minimal dust end muchre will likely be 10 behind. The model margin Inciental and b9ign maenal hmm
the remains and Me incudentual and foreign maenal void be seemed area houil by law. TommN rmaire Mlldameaanimlly
Wlverimdmom amau man and pleadIna a designated container or um. Cmmsadmmlgp la ampulwN uMino
slnpNhapnfimN rocopNvom u OMJlebl Wsw.
OPENIMO OF THE CONTAINER
The cremamry may Only Oman the container l ddina the unCremtled human remains m Aim odd circumstances, such a¢m mnfiim Ins
idenory Or dienional oral ensure but no materials encased whim might injure employees or damage the mmalory pmpeRy. N
human TmsmS am delivered In a conum.r whim Is not enbbM for emmaaon such u cenmonm or moral mekeh u»
mmry will imhNmeram bemovedArnesuNbbwnblwrbfoa Ite¢none he re�Mlnt omningo1a
Wntaimathe Van Van¢M1r Orremwel Of rtmeins will pemnducLLtl b¢IpB a witness andwill bedodoneIn Itrivxy, wM dg dgnM1yaM MWct.
IDENTIFICATION OF INK EASED
Name of Otte) Charles DavN songs,Jc Manic]
Men es tal Station
bad Nnwm PLdmm: IN John abash Hudson Film Ny IM9
PIGS of deem 3518 SurgOyM was Hudson Fain, NY 12M
See'. ®M OF Arm 58 We: 10IM1961 ma of mans:07117M020 EMna Ntigfa' 180
Ow Om NwWVSnuirerIn wi mmmrs MIl be"Named.
Minimum Cremation Casket, Florence Casket Co. Candooard/Pine
PERSON IN CONTROL OF O SPQ4 TN)N
(Formal in Shod of useful BONE Of the Amowmg)
I amMb am the duigretM agent M the demved dmgumd in a wN or wnllen Irgbument execuled Wnumnm Pudic
:M Sec 4WI
Areas basenornWKdge ihmihetlema¢NemMNaNnpenm themeM Wmuamto PUNic HUM rPewicHm 4201 Se
well iy direcdoN for Me de'.Wsibon ol his a her remains and dues am the Pomnile) M1aving pdonry under PUCIicHUM Lon'
sedlon Q01 and Mw the Night Is adhorize mmadon of ins remains of"moment Wager relationship to he d "Sad is me
moon
Charles David Scully, Jr.
DOS legs f wave CGRo) Page 1 rid
Authorization for Cremation and Disposition
pneertdwm M.uaeamw)
Number;2 oeaa on. TM°aurvmnp apou
1. ApereOn tlesgnalM In whang pursuant b Public HUM Lax SetlMn 42011]);
Z. Toy,Wrvivirq seems@;
L. They surviving domi paMer,
1 Any aurvivlrg Child eigMUn yens Of Me or cider.
A Asural parent)
A Apr ing sibling egM1men seam M or Or older,
& AIerMAy agpOii Moscow
T. Any person(sl annual same of age Or dram URbed to Mare in Me whom and who lI clomatln mrsoMei ,to Me MtteW1
& A a ury appointed ad udnry of Me,estate)
p. A"I he herd or sleeve full has emcuMd a wdpan SMa ent purauanl b Public Health U,Sedian 0201y)I
10. A cniH fiscal OMmr of a county or a pi Win nalmorVpeil purauarm to Me SunOgap'a Court Procgaure Ape;
10s. My error Mreen and as ac9ng On behalf Of Me demo and who has NeWed a wisher staemam pursuant to RAW HamM
Lax Secron 401.
( EE o(Me Mlowlrrg)
�1s IWe M1@rebY alfiim MMMe away MMedweaM acw natanrein abaNery, Massacres, powBl full. MiwGve imelem.
or=loecdva devil and that any Push Moderateness remmrea pnortomeucNpn of Mrs AuMoMm PAm Fords Follumbmnwa
prior m cmnWon may Muft In ham mBm cmmMm and cmnamry Poraonml.
May arem that Inabuctl0ns head roan given m Tood lGFwr
regarding Me rzm[val Of any m nal poppp or obw M'n0 of valor whits any Damon sign,%bekw or any handy melee of Me
C aW wrather,to gears, Pits year,CM1nabry
in rot responsuble MNa mmoM Of pdeeonal Armsfrom the mMelmr or horn the remains of the MmaM Parmnal ama Its In the
COMUimr or wM Mee sim MII day dmr d by Me cmntllon process antl cannot M eMei a rcwmmeon.
VAN,albs NMor Pone Vier Crencery M1�n
to cmnN One mmtlm o/tba rMCNsad.
(jiOPTIONAL)
Was Mmby i uMorla Me named herself dbacmr to provide for delMry m and cmmabon by an s 1N
mry, Ndeamed necessary In Me opinion M r mp mrts Me bun) diva and m area"NIs form vide to pro Me correct name and
.remadamn a Such ammam cram nowy.
FINAL DISPOSITION
TMpeeon sutnmerM to remove Me memmM remarna of May Mel hem Me aemam7i6.
Name III Murder consul Harty
Manes: 82 Broadway, Fed Edward NY 12838 phyn, 5W47-SHIS
The oem ember of heft will be dmp Nas Mines
aeMaN m8mya scary
If for any mm Me name abm b AM may pmANMn of the Omm rmnam.
Paris Y Cemetory a aulMr¢ed m ghe pm on Of
fuel
Va emminab M.B. Ki Fumrel Hero by chicory,
in ease or by WMm mail. p Chadee Darn] yonly Jr.
OOS15g&f(Ne¢ 0AR0) NUw Iss" 5
Authorization for Cremation and Disposition
(andsalme madam
LAVA unMRbN N R at If his etains am notdYme]µMm 120 days of
Pi Lnmatay
may Cspnse of Ne examine in
an irretxevebe manner, such as ey worenn9.
CREYTON CONTR NE"M
QnJpp(ONE dine Idlawmyf
An um to w used as a CMuiner for Me ona ehad da mina nee been puMawJ han
and is demnbad as slow
Ofm uMeredM that BMa an 'a Was"Ito had Me enure cremates remains,an additional Mal mnearKK may W uead no haiwry,
M um6rgl}pt Ourm�. I indyYvid NMitmum Is WrmwMardthemisepmvded
P'me Vw Cremerory
A+�d� vall platytM cremated remains In
a raged tmodaryw verse hit CYiKry.
Me AUNmMa Form was ptowded by TW What was executed at
M B. Kii Fungal Home nv�w mu
Bf Broadway, Fad Edward NY 12M nw"uww,wl
cow•and is signed by tM Nail director as woman to its
erecugpn
IAM)haW assume a completed copy of the AUMo aN Form.
TM penon(s)Wmtlfled below Mlaw the pratims)In wrmol a shambles,who by signing MY AWM aflm Form,aN gs)
W the Bacursq alW emp mm of the Witnestles contained In NN AuMwlaabon Feet and nationwide)the foregoing.
So NN ITIh �M JuM .� 3
Some
3"n- Va 3cally
Minn
t W JMn Stress, XWson FaM, NY 13B3g
TITHEU:
S$:
Todd
11379 hMwmnvxmn a+�ead
Chi Dam Smily Jr.
OOS18W(Rev. Dli Isigi