Lukaszewicz, Sandra A. i
own U LLee`2:S �G�'l�f
rmE VIEW CEM[TERY and CREMATORIUM U
QUAKER ROAD, QUEE 7[3 Y. NEW YORK 12801
98-4726
(518) 793-9777
Funeral Dirictor A/
N-line ,�(� zip Case No
VaLe of Cremation
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'1'inr Cremation Started �<
'fine Crem Lion Completed
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DISPOSITION OF CREMATED REMAINS
1 hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangement - please specify:
send to Carleton Funeral Home
If pulverization of cremated remains is requested, check here x
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
Itoad, Town of Queensbury.
:1. An authorization for cremation properly signed by the nearest next to 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 reasen'bf, or connected with the cremation of said remains anti/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.
F. 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 $10.00 charge for this service.
Cremation, Administration Costs and Recording Fee:
Adult rf 55.00
Children (age 13 months to 12 years) $10.00
Infants (stillborn to 12 months) $50.00 ""'
TOWN OF QUEENSBURY
PINE VIEW CEMETERY /
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
1
AUTHORIZATION TO CREMATE
'f lie undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulations to cremate the remains of:
Sandra A. Lukaszewicz
Name female
Sex
104 River st Hudson Falls Ny
.Street -, 12839
%ity) (State) - Zip Code
who died on the 17th
day of _ Ma 192, _
at 104 Main St, Hudson Falls , Ny 12839
Place Address ——
Name and address of nearest living relative or name of person authorizing cremation:
Mrs KnIlY Smith, RD 4, Corinth Rd Box 489 e
Name Address 2804
Relationship to the deceased
dau hter
Name of the funeral home carleton Funeral Home In--.
IMPORTANT:
I represent that to the best cif my knowledge, the deceased has o has no acemaker in his
or her body. (CHICLE ONE)
1 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 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, or connected with the cremation of said remains
as directed, whether such claims or demands are, or are not, wholly groundless, false or fraudulent.
1
Witness1L � . �
ig ure o Relative or Legal Rep.
68 �Main St Hudson Falls NY 12839 R Address NY 12804
Address
Signed on this date 5/20/91