Blake, Dianne OF QUEEN,50ur
PLNE YIEW CEMETERY AND CREMATORIUM
�y
QUAKER ROAD, QUEENSgURY NrEW YORK 128N
(518) 745-4476 (518) 745-4477
Funeral Director /+
\amen � Rlit,
"
[ ���� .. Case# 55
Date Of Cremation
Time Cremation Started
Tlme Cremation Completed
Type of Container
Ar cr taw or� S C �
Remarks
IN g�1S
oV� 1;0 0
(oo L 10 :10
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I
57
Town of Queertsbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12844
Cemetery Ofka: (518)745-4476, Crematorium: (518)745-4477 '
Autimmization to Cremate
The undsrslgned requests and aufxwb s Pine View Cramatar um,in 800ordence with end sabjed to Its Rules and Regulations.to
cremate the renwins of:
Dianne Lynn Blake F
(Name) (Sex)
3.34 Ridge Road Queensbury NY 12804-
(Shvet) (C" (SUM) (Zip Cam)
who died on 24th day of January 2008
at 334 Ridge Rd, Queensbury NY
(Place) (Address)
Name and address of nearest IMng r Awh e or frame of person sudxwb*V aemallon:
Robert Blake 334 Ridge Road, Queensbury, NY
(Name) (Address)
Relationship to ttte deCea9ed Husband
Name of Funeral Fknrse Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my tawwladpa,the deaeesed(has)or{has no)pacemaker,deftrillator,battery,benery pads,power
cell,reftearve in i tent or radioactive dwhm In his or her body.(Cfrde One)
I ow*Viet I#rave U power end aWrorizetlon to anange for the crenwk n o1 the remains and to direct the disposition of the
cremated remains,that arty personal possessions have eNhar veers removed or maybe dsM Dyed,and agree to prdeM defend and
save hannbee Pine View Cramewrliza born any and all claims and der nards for loss or dernapss whist may be made againd them
by reason of or eorencived wNh On cmnedon of said rank as dnscfed,wftedta such CIO,s or demands are or are not wholly
� 68 Main Street, Hudson Falls, NY
�Tn
(Address)
334 Ridge Road, Queensbury, NY
pIpieUm end Address of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crernatmiurn to dispose of the cremated remekts as foNows:.
Mail to
Other aroMpmnents-Please spadfy:
If pulve&wdon of Cremated remains is requested,dnadt here XX
RevWjm Apri118.2007