Van Eeden, Jacob J
� 111
O .
0 UEE
PAYE V7E B
'' CEAIETE l-1
QUAKER ROAD RY AIV� CRE
Q�F'NSB MATORIUM URY, NEW YORK 128N
(S18) 745-44F'
(S 18) 745-4477
Name 4
Funeral Director �Jglo� CSC/
U4,
Case # q?z
Date of Cremation
Time Cremation
Started n
Time Cremation1,00 A
Completed
Type of Container +
Remarks ; Claw ir� � �F
:2Q
i
i
Town ofry
Fine Vtew CW""and Cm
Cetne MejojiuM
l?e4uaker Road,Q tsbur+, New York, 12804
rY OMce:(618) �464
4761
Crematorium:(518)7454477
A��to Cremate
C"WMM the and�Pk*Vlew Creff+etar m,In e000rdmm wth aref
Jacob and Rk�dons
Van Eeden to
( male
26 West Beacon St. ON()
falls, NY 12801
(Sheet}
( ) (State)
wl�o died on 6 th {ZIP Cade►}
day of November 20 09
at The Pines Warren St.
(piacg} Glens Falls, NY
(Adte9j)
Nam and sddrem of nears*"V or ne�rtta d pis
Stephanie Hod son 47 '
�m6,} Loudon Rd. Sarat a S rin s Ny
ReWwMft tq Ow 00Msd daughter
Name dFoxNalUana Carleton Funeral Home, Inc.
IMPORTANT.
'Mmmo that Ia tha tax of mr
C"'Maoec "MV*t a ra ftft "ftvk hm or(hsa raj pe W
�Y-(Circle(3�ne 'ft%dW*W ', y Pecp,Power
1 Decor their I trerre*A pow
power and autlxwftngon 10 arnwW for the
I�lrfe Vfew��heroON aryt b dlrecx ehe melon of fe
by�Mina I da d A trfesaattet "*said term,' ' yr#arcs or A°Ie me*g c** om
PAR bbe or�. char such "�S'e°a��,Dp�R diem
l�,J.�/ �t�9 ard�rr sre or eye not tMx�ily
� Carleton Funeral Home, Inc.
(WIM" (ddrsas)
Saratoga Springs, NY
( �Ott ar t.,egai Repraseryadys)
Stpnee on thk! r 6, 2009
Dbposk m of C,twmbd Paneft
I hwebr dWW Ike Vkwoen*"— '0 d the vemsted,wn@h s ss tNows:
Ud to
0vw ass_Ptea'sa aPw-'
tf pufna+ °fOWMWMrAO mw ted.Che*here
urrbiOc A01$,2007
i