Hendricks, Robert Dr. DDS zo rnN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
(� (IFuneral Director_
Name 1�� c� V,jrLc ' Case # 31t
Date of Cremation
Time Cremation Started 7"46 h
�o Time Cremation Completed +b' �i')
Type of Container ("rhoci c ( - 2 j' C
Remarks :
NUVE 1,30/1h
!b
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 accordance with and subject to its Rules and Regulations to
cremate the remains of:
Dr. Robert M. Hendricks D.D.S Male
(Name) (sex)
46 Dorlan Drive, Queensbury, NY 12804
(Street) (City) (State) (Zip Code)
who died on 1&h day d July 20 09
at Glens Falls Hospital, Glens Falls, NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Sharon Hendricks, 46 Dorlan DRive, Queensbury, NY 12804
(Name) (Address)
Relationship to the deceased Wife
NameofFuneraliiome M.B. Kilmer Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceaspd(has_s)_or no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have 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 9W
�8 connected with the ation of said remains as directed,whether such claims or demands are or are not whollyground"J Ise or fraudu j
c
���1 vL f (Address)
(Signature and Address of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as folbws:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006