Naccarato, Grace (-ro q+N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM'
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Name L�SCQ �V�,iC4�-1 f6 Case #
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Date of Cremation aeKkr Z�
Time Cremation Started 'I (-b
Time Cremation Completed JD :oo M
Type of Container
Remarks :
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Town of Queensbury
Pine Yew Cemetery and Cr+emetorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Auftwization to Cremate
The undersigned requests and authorizes Pine View Crematorium.In accorderm with and subject to Its Rules and Regulations to
cremate the remakes of:
Grace E. Naccarato Female
(N1e) (Seat)
118 Circular Street, Lake Luzerne, NY 12846
(SIT") (city) ( ) (Zip Code)
who died on 16th day of December 20L 09
at 118 Circular Street, Lake Luzerne, NY 12846
(Place) (Address)
Name and address of nearest Wing rek&e or name of person au&mnzkug cremadon:
Scott Frasier, 118 Circular Street, Lake Luzerne, NY 12846
(Name) ( )
Reistionshiptoftdoceesed Son
Name of Funeral Home Brewer Funeral Home, Inc.
IMPORTANT:
I represent then to the best of my Ivrowlixt ,the deceased(hes)or aker,dellIbrillatour,r,by, pack,powerp
cell,radioactive Implant or radioacd a device in his or her body.(Ckde )
I certify that I have full power and authorbation to arrange for the o unation 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 meson of or connected witch the cremation of said rerneins as directed,whether such claims or dernerrds are or are not wholly
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groundless,"se 9r.:(Signature and Address off Relative or Legal Represer4alive)
signed on this date: �' Lo /
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated rends as follows:
Marl to
Other arranpemerds-Please specify:
If pulverization of a9mated remains Is requested,check here X
Revision:April 18,2DO7