Urban, Kurt r
OF QUEEVBUPy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director '4a f�
Name Case#
Da to Of Cremation %t6
Time Cremation Started_
Time Cremation Completed
Type of Container
Remarks
A 1 u 1 ` i o
IU r
I
Town of Queensbury
Pine Yrew Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12W
Cemetery Office:(518)745-4476,Crematorium:(518)745-4477
Authorization to Cremate
The undwWgned requests and&0mrizes Pk*View Crematorium,in ea=dence with and subject to its Rules and Reputations to
cremate the remains of•.
Kurt H Urban Male
(Strest) 5 t h (City) (Swe) (ap Cam)
who died on day of
August 20 06
at A cf" (41
( ) I wwwss)
N(a end addre�ssof neeraat whg reievveror nemeof person a ftm a r q cremation:
fri5'IK W/� �1(/ Z�( T MgI'i d tlr ✓� }
(Name)
Aelatonshlpto the de0ea9ed --
Name ofFunYWHome Carleton Funeral Home, Inc. T_
IMPORTANT:
I represent that to the best of my Imowiedga,rite deoeeeed(has)or(has no)pacemaker,deNbdliator or any other battery operated
device In his or her body. (Ckde One)
I certify that I have full power and eu0tortxatlon to arrange for the aermtbn of fhe remake and to direct the disposition of the
cremated remelns,tint any personal possesslore have either bow removed or may be destroyed,and agree to protect,defend and
rive harmless Pine View Cnunstodum from any and al dshne and ri n 1 f In far foss or damages whirls maybe made against them
by of or cofxferlett with the aanoft of sold remairfs as dirflctad,wihed w such dahns or demands are or are not wholly
(/V�� 68 Main St. Hudson Falls
(Address)
d)-,,, 01s ✓/i
Address of RPM"or LOW Represaltative)
sgned on this date:
Lion of Cremated Remains
I hereby dired Pine View Cremetodtim to dispose of the cremeled remains as follows:
MaN to
I
Other arrangements-Please epadfy: _
if ptdver of cremated remake Is requealed,Clack here XX
baton
Revh1on:January 1,2006