Blake, James Dr. OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name D j c;rq Jr U1
Case#
Date Of Cremation 5 /at It(,
Time Cremation Started ) ' ik AN
Time Cremation Completed_ ic'. CCb
Type of Container ("',J Lr,. d ('� {z �hsF
Remarks
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05/21/2006 15:45 19107544290 OFFICEDEPOT PAGE 02/03
• MHT el 'OG 02:23PM LEDUA P.2 ^
Tom of Quo*nsbury
Pine View Cemetery and Cremetodum
21 Ounker Road,Queensbury, New Yo*, 12804
ComsterY Office:(slit)745447a,crematorium: (518)74&"77
Aug oriz®8on to Cremate
The w derslpned ropuests and auuwlms Pine view Ctarnatoriwn,in a000tdw=wkh and SLtI ex toils Rules ane Repuleuorw to
cremate aie rwroft of:
,qqn!,R.`�� Q yak 1`�AL
(Name) (sage)
QTlp
(slrael Ply) rate) (ZIP Code)
ono died an �.1 ^ dayof 2UA
at
Name and addre®e�a2(n�esest arlrB rela8ve or name of Derwn e�arotl�n0 merlo
e n,
e.N - r
Retduo AV a am deaemad L oNsk
Name of Funeiai Mw
r�
IMPORTANT:
I rapreewra I t to ft bust of my' the deoeemed(hss)or(has no)pacemaker,da$bTiyator or any Otherkauery operated
device In his or her body. (Ct�ste Cna)
I ON*that I h0m curl Power end aulltwVAOn 10 e=MP for the taaetatlon of the remains and to dhod the dl spos►tlon or the
aarnaled ramahs,the wW panMortsl pmmobm hove anther bean reowrad Or may be deettoyed,erd aprea to pralock deWd and
care ha mkm Pho view Ommolmkon kom any and or dolor and demands tar Moen or dwnsW wltbh may be made ap hd dram
by mwm or cr w I F*1 wM Me Qwndb,d sold cements a9 4 Wild,whether auch dWms Or dntlende are or lrns not MWy
groundlem false ar traudubnt.
prra4+re ertd of WaletM or I ) e. r s pa
t3Nr,ed en this dew ' ) .amp rd - x yG 9
Dteposi m of C+mmidso Romaine
I hereby drw Plee VkW Craetetori m to dtelgea d the as I I I rem*w as fouoyre:
Mov to
. .corer anartpelner>,+e-Pteass spedM.�� � —�—
It
puhrafaatlon of txsmated mmahis is requed dredc l+ere
RawLrMon: 18rw 1,20M