Henderson, Jeffery OF Q`Z EE BUP
PINE VIEW CEMETERY AND CREMATORIUM
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QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
II (( Funeral Director CC"1� '
Name Qec�, }1tne�ct�p�,
Case#
Date of Cremation
Time Cremation Started
�1: 10
Time Cremation Completed 20
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Type of Container r _
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Remarks
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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 arrdwrizes Pirre view Crematoriwn,In accordance with and subject to its Rules and Regulation to
cremate the remains of:
Jeffrey Henderson M
(Nam) (Sex)
5 tpbb��s�un����•. Queensbury NY 12804-
(')11/08/2006 (City) ( ) (Zip Code)
who died on day of 2Q_..—.
F
Glens Falls Hospital Glens alls NY
at
(Pk") (Address)
Name and address of nearest WAV reiatlre or name of person nulfwrtdrq cremation:
Mrs. Donna Henderson 5 Cobblestone Drive
(Name) (Address)
Relations*to the deceased Wife
Name ofFurwalHam Carleton Funeral Home, Inc.
IMPORTANT:
Imposer that to the best of mf bmcwite 1p,"deceased(has)or(has no)pecernalter,defNxifuefor or any other battery operated
device in his or her body. (CGcle One)
I certify that I have hat power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any F p m0 cal possessions have either bean removed or may be destroyed,and agree to protect,defend and
save harmless Pere View Crennimi rn from any and an dab. and demands for foes a rfernages vrtrich may be made agakrat them
by reeson cf or Corded with lute of said remains as directed,whether such dalms or danwW are ar are not wholly
groundless, or Tteudulent.
7*7 (Add—,
(w 77 and �i of Relative or Leo Representable)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine view Crematorium to dispose of the cremated remains as follows:
MaN to
Other wrangemenrs-Plaaee spedfy:
if pulverization of cremated remains Is requested,check here XX
Revision:January 1,2006