Henderson, Louise 1 J
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ritlE VIEW CEMCTERY and CREMATORIUM
QUAKER ROAD, QUEEN$QURY, NEW YORK 12801
(5I8) 798 4 72G
(5I8) 793-9777
Funeral Dirictor z47 S C,4 AKI�-
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Vale of Cremation
Tints Cremation Started
Time Cremation Completed C-2:014 6 M
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject_ to its Rules and Regulations to
cremate the remains of:
LOUISE S . HENDERSON Female
(Name) (Sex )
_Victor Herbert Condominiums Lake Placid, N . Y . 12946
(Street ) (City) (State) (Zip Code)
who died on 14th day of November, 19. 92
at Victor Herbert Condominiums , Lake Placid
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Jean Betz Mirkil-Charles A . K. Pearson & Jay Mirki], 3315 Wa,�ers (iAill Dr
(Name) (Address) Alpharetta, Georgia 30202
Relationship to the deceased Daughter & Sons
Name of Funeral Home-M. B . Clark Inc . . 22 Saranac AvP . , Ta kes Placid,
New York
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange
for the cremation of the remains and to direct the disposition of
the cremated remains, that any personal possessions have either
been removed or may be destroyed, and agree to protect, defend
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
R F. Clark 2� qar nest AvP _ , Takes Placid , NY 1 946
(Witness) (Address)
_ Authorization given by telegrams [31
(Signature of Relative or Legal Rep. and Address)
Signed on this date :_ Nov. 18 , 1992
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematorium to dispose of the cremated
remains as follows :
Mail to Roser11.1_ Cemetery Attn: Mr . Sam Ca abres
5800 No . Ravenswood chic'a _ Tll 60626
Other arrangements - please specify :
If pulverization of cremate remains is requested, check here
POLICIES, RULES AND REGULATIONS
1. The crematorium will be open for cremations 5 days a week
7:00 A. M. - 3:30 P. M. Monday-Friday. No Holidays or Sundays,
arrangements can be made for Saturday. Prearrangements by
telephone for acceptance of remains is necessary.
2. Pine View Crematorium is located on the grounds of the Pine
View Cemetery, Quaker Road, Town of Queensbury.
3. An authorization for cremation properly signed by the nearest
next of kin or other authorized person stating that they do have
the power and authority to arrange for the cremation of the
remains and to direct the disposition of the cremated remains,
that any personal possessions have either been removed or may be
destroyed and agree to protect, defend and save harmless Pine
View Crematorium from any and all claims and demands for loss of
damages which may be made against them by reason of or connected
with the cremation of said remains and/or disposition of said
remains as directed, whether such claims or demands are, or are
not wholly groundless, false or fraudulent. This authorization
in addition to a regular burial permit must accompany the
remains.
4. All remains must be encased in a casket or suitable alternate
container. Caskets and containers must be of combustible
material. No styrafoam or plastic containers will be accepted.
5. The question relative to cardiac pacemakers must be answered
on the authorization to cremate form before the remains will be
accepted.
6. Unless other arrangements are made the cremated remains will
be mailed via Registered U. S. Mail within three days of cremation
to the funeral home handling the service. There will be a $18. 00
charge for this service.
Cremation, Administration Costs and Recording Fee : Adult $155. 00
Children (age 13 months to 12 years) $90. 00 Infants (stillborn
to 12 months) $50. 00
Yx• -
MESSAGE ORIGINATING DATE FILING TIME
NUMBER 1002214a322 OFFICE )LOS ANGELES CA 11-17 1112a
TO: M B CLARK INC
ADDRESS: 27 SARANAC AVE
CITY—STATE&ZIP CODE: LAKE PLACID NY 12946 I
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_. ....,_,I.: JEAN BETZ MIRKIL_.._AM.—-ONE
_..0�'__T�k��.....C�T1LI?KEE�i_._QF .LDIIS.SE .u....-__5.........
HENDERSON AND IT, IS_.MY_DESIRE.._ $., T..,.W.AS__._MY__MOTHERS WISH._THAT--SHE_
BE CREMATED.
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j SIGNED: _ JEAN BETZ MIRKIL. DAUGHTER OF LOUISE U-S ,sHENDRI2
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MESSAGE ORIGINATING DATE
NUMBER )1-004749k322 OFFICE ) ALPHARETTA GA 11-17 FING TI E
TO: M B CLARK INC 5185233337
ADDRESS: 27 SARANAC AVE
CITY—STATE&ZIP CODE: LAKE PLACID NY 12946
_JAY MERKEL AS HER SONZ r HEREBY YAUTHORIZE THE
_ _- ...._.CREMATION OF_ MY MOTHER, LOUISaE U-S HENDERSON� IN
_ACCORDANCE WITH HER WISHES.
SIGNED: JAY MIRKIL
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MESSAGE ORIGINATING DATE FILING TIME
NUMBER 1002296k322 OFFICE /HERMOSA BEACH CA 11-17
TO: M B CLARK
ADDRESS: 27 SARANAC AVE I
CITY—STATE&ZIP CODE: LAKE PLACID NY 12946 i
CHARLES A K PEARSON, AM ONE OF THREE CHILDREN
OF LOUISE U S LLHENDERSON. AND IT IS MY DESIRE AS IT WAS I
MY MOTHERS WISH THAT SHE BE CREMATED.
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SIGNED: _ CHARLESHA K�PEARSONto
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