Liebertl, Emily OF QUEEN,50Ur
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QLIEENSBURY NEB, YORK 17804
(518) 745-4-476 (518) 745-4-477
Funeral Director
N a m e
Case# 3s
Date Of Cremation
u USA oo
Tame Cremation Started U()
Tame Cremation Completed
L;so
Ty ?e of Container Ld
Remarks
Town of Queertsbury
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 eu lhorizes Phhe View Crematorium,In eocorderm with and subject to its Rules and Regulations to
creme the remains of Emily Rose Smith bye e tArj F
(Nome) (Sex)
8.1 Hunter Street Glens Falls NY 12801-
(street) (City) (we) (Wp Code)
who died on day of 08/06/2008 20_
at Albany Medical Center Albany NY
( ) ( )
Name and address of neearmet living rat &m or name of person authoriafg cremation:
Michael Lieberth 81 Hunter Street
(Name) (Address)
Raiattonship 1
0 the deceased Father
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge,the deoeasad(has) maker,detibd iator,battery,baaery petit,power
cell,radioective implant or nKkwktive device in his or her body.( )
I oar*Chet I have U power and sulfiartmRlon to arrange for the cremredon of the remains end to direct the disposition of the
cremated rameahhs,mst arty pereonal poeseesione have aielhar been rarroved or maybe destroyed,and agree to protect,defend and
save harmless Pine View Cramlorlum from any and all rinires and demands for bes or dernaps which may be made ago*
by reason of or connected wkh do c rarneUm of acid remains as dkaceed,whether such rime ntra or demands sre or era not wholly
groundless,false or
68 Main Street, Hudson Falls, NY
(Ad&ws)
81 Hunter ,Street , Glens Falls, NY
(S4nature end Address of Relative or Legal Representative)
Signed on this date:
Dbpostion of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:.
Mail to
Other arrangemerm-Please specify:
tf pulverization of cremated remains is requested,dheck here XX
Revision:April 18,2007