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Seybolt, Thelma 70 WN of QUEEVBUrkY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSHURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director k:z;:%// N Name �/�!►'! /. Case # 1 '7 Date o f Cremat i en Time Cremation Startedh/'16 f1110 Time Cremation Completed /0-2- 1 / /m Type of Container T 2'Y'0"0, Remarks : 3 A x9"M / %qg/4 rM Il /I ZZ TOWN OF OiJEENS©URY PINE VIEW CEMETERY a CREMATORIUM Quaker Road, Queensbury, New York 12604 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: Thelma E. Seybolt Female (Name) (Sex) 16 Homestead Trailer Park, Queensbury, NY 12804 (Street ) (City) (State) (Zip Code) who died on 9th day of July 19 9�_ at Willowood of Williamstown Williamstwon MA (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation : Joseph N. Seybolt 16 Lester Drive Queensbury. NY 12804 (Name) (Address) Relationship to the deceased Son Name of Funeral Home Regan and Denny Funeral Service, Queensbury, NY 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 sav4 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 frau ulent. V4ttneis) ( ddress) ignature of R tive or Legal Rep. and Address) Signed on this dates � � �8' DISPOSITION OF CREMATED REMAINS I hereby direct Pine View Crematorium to dispose of the cremated remains as fulluws : Mail to 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 $20 . 00 charge for this service. Cremation, Administration Costs and Recording Fee: Adult $195 . 00 Children (age 13 months to 12 years) $115 . 00 Infants (stillborn to 12 months ) $75 . 00 * Additional $50 . 00 charge for cremations done after 3 : 00 P.M. Monday through Friday. Cremations done on Saturdays will be charged the additional $50 . 00 . REGAN&DENNY FUNERA.L 53 QuaUr Road A-- Queensbuy,New Ymt 1280-", "Customer's Designation of Intentions" Name of Deceased: Thelma E. Seybolt Cremation: JulYlb 1998 Pine Viw Crematory, queensbury, NY (Scheduled Date) (Location) Manner of Disposition of Cremated Remains: dBuri.1 at -2(, L-IIky-L LFIIlt El Return to Family 0 Entoruhment at 0 Other (specify): i herehy designate the Disposition of Cremated Remains and aeltnowledge receipt of a copy of this form. Z Joseph N. Saybolt Son (Printed Name) (Relationship to Deceased) 16 Lester Drive (Address) Queensbury, NY 12804 (518) 793-3928 (Telephone N.-I—) "Cremated Remains which shall not have been claimed within 120 days from the date of i cremation may be disposed of by this firm by placement in a columharium." John D. Rutski , A47� 7/9/98 Printed Name of Funeral Director Signature of Funeral Director Date or Undertaker or Undertaker TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS Cremation: (Actual Date) (Location of Crematory) Disposition of Cremated Remains: (Manner of Disposition) (Location) (Date) Name of Person Malting Disposition Signature Date #9 VHM.-Funeral Home Co" YELLOW:FAUIAY COPY PINK Crematory Copy CUSDMN Rev.4/96