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Town of Queensbury
Pine Yew Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)7454477
Authorization to Cremate
The undersigned requests and acdhorass PUte View Cre n Aorlumt,In accordance with end subject to its Rules and Regulations to
cremate the remains of:
Robert Blake M
(Name) (Sex)
12 Vista Court Queensbury NY 12804-
(Sueet) (City) (Swe) (ZJp Code)
whodtedon Thirty First day of May 2009
at Glens Falls Hospital Glens Falls NY
(Place) (Address)
Name and address of nearest living rreb&m or name of person auMortdng cFematlon:
Helen Blake 12 Vista Court, Queensbury, NY 12804
(Name) // (Address)
ReWWnsl*to ttlB deceased
Name ofFrmerai"ome Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to fhe best of my knowledge,the deceased(has) ,deftgatar,battery.battery peck,power
rad
cW.radioactive impient or oective devioa in this or her body.(C )
I oar*that I have full power and eudwri¢ation to arrange far the c remedpn of the remains and to direct the dWposRion of the
cremated rwneins,that any personal possessWo have either Crean ramovad or may be destroyed,and agree to prolect.demand and
save harmless PMe View Crematorium from any end ad claims and demands for bse or damages~may be made against them
by reason of a connected with the cremation of said remains as dkWed.whedw auch derma ar dertr9rtds are or em not wholly
flrvundless,false f(,/tp1�I-e�J_
68 Main Street, Hudson Falls, NY
``LL {Ylfdrtess) (Address)
(Signature of Relative or Legai Representative)
Sgned on this date: / T
Disposition of Cremated Remeft
I hwreby direct Pine View Crematorium to dispose of It*cremated remains as Iolbws:.
Mail to
Other arrangements-Please specIfy:
tf pulveention of cremated remains is requested,check here XX
RevWon.April 19,2007