Blake, Richard �S
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURY NEW YORK 12844
(518) 745-4476 (518) 745-4477
/11 Q Funeral Director LoLr 0" _
Name- Ej"�CrL( aIQ
CeSe# L'y
Date Of Cremation 13
Time Cremation Started
Time Cremation Completed
Type of Container
Remarks
33,i5 P�
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery Office: (518)745-4476, Crematorium:(518)745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in acoordance with and subject to its Rules and Regulations to
cremate the remains&
Richard Sewell Blake M
(Nam) _._ (SOX)
6103 Regency Park aptansbury NY 12804
(Street) (City} (State) (ZIP Code)
who died an 9th daYof November 20 06
at
Glens Falls Hospital Glens Falls NY
(Place) (Address)
Neme and address of ne®est living ww4e or narne of person auVxxt rng cremation:
Matthew Blake 425 Glen St. Apt. 29, Glens Falls, NY 12801
(Name) (Address)
Son
Rekdkx *dp to the daoeased
Name of Funeral Home Carleton Funeral Home, Inc. T_
IMPORTANT:
1 represent that to the beef of my Iorowledge,the deceased(tree)4E i pecenneW,def ilge Or or any other betto y operated
device in his or her body. (Cirds One)
I certify that I have tug power and atOK woatbn tD aaarge for the cremation of the remains and to dlrW the disposition of the
cremated remains,that eny personal possessions he"either been renaved or may be destroyed,erd agree to protect,defend and
am harmless Pine View Creoretorium from any and aN disirns and dernends for loss Of d8n%Ws rrfkh may be made apa:>st them
0yiFF
n Orin the aeration of said remains as directed,whether such clehas or derriends are ar are not wh*
or NUKL48A
Carleton Funeral Home, Inc.
(Wkness) (Address)
��kA 425 Glen St. , Glens Falls, NY 12801
(S g�riaWre and Address of Relative or Lap[Representative)
scorned on this date: 1( �( S / cc,
Ofsposition of Cremated Remains
I hereby direct Pine View Cremsiorksn to dispose of the uernated remains as Willows:
MaN to
Other arrangements-Please specify:
if pu vertMion of cremated remains Is requested,check here XX
Revision:January 1,2006