McKee, Clarence rl-0 WN OF QUEEVBU�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director )-g) 41
Name f'/?g'1qC)j5 A)C��� Case # f q6
Date of Cremation // `j-- yzoc/
Time Cremation Started 2�/q l M t
Time Cremation Completed /6 r
Type of Container
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM b
Quaker Road, Queensbury, New York 12804
Phone(518) Crerrtat9rigpr 745-447T(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:
Clarence "Mac$" McKee Male
(NAME) (SEX)
38 Bridge St. , P.O. Box 166, North Creek, New York 12853
(STREET) (CITY) 'r :> . (STATE) (ZIP CODE)
who died on the 2nd day of April 20 01
at The Glens Falls Hospital — Glens Falls, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative:or name of person authorizing cremation:
Mrs. Jane McKee —, 38 :Bridge .St. , 'PO Box 166, North Creek, NY 12853
Relationship to deceased Wife
Name of Funeral Home Alexander Funeral Hone, Inc.
IMPORTANT
I represent that to the best of:my:knowledge, the deceased 2LM has no pacemaker in his)gpw
body. (CIRCLE ONE)
I certifyahat I havewthe.full:pgwer�and iut4RrizatiQn-to,arrapgg..for,the cremation of the remains and
to direct the disposition;,pf; a rerns>;edsr tainly,;that. ny,ps oral 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
a7cla'
m by reason of or,connected with the cremation of said remains as directed, whether
(I'sus or demands are or are not wholly groundless, false or fraudulent.
3809 Main St. , Warrensburg, NY 12885
(WITNESS) ; .(ADDRESS)
? A=L e St. , PO Box 166, North Creek, NY 12853
4.SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: April 2, 2001
DISPOSITION OF CREMATED REMAINS
I hereby direct Pine View Crematoriur i to-dispose of the cremated remains as follows:
Mail to
Other arrangements-please specify: Return To Funeral Director
If pulverization of cremated remains is requested, check here X
POLICIES, RUI.ES 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, arrang�:ments 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 ani 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 destroy.ed.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 ci connected with the cremation of said
remains and/or disposition of said remains,as.&klcted,whether such claims or demands are
or are not wholly groundless, false or fraudulent. " its authorization in addition to a regular
burial permit must accompany the remains.
4. All remains must be encased in a casket or suitable vIternate container. Caskets and
containers must be of combustible material. No Styrtfoam or plastic containers will be
accepted.
5. The question relative to cardiac pacemakers must be ai,,swered 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$225.00 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. Morday through Friday.
Cremations done on Saturdays will be charged the additional$50.OG.