Lukaszewicz, Bernard TOWN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Date of Cremation — Zp
Time Cremation Started °�-
Time Cremation Completed
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or 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:
Bernard John Lukaszewicz Male
(Name) (Sex)
104 River St. Hudson Falls,NY 12839
(Street) (City) (State) (Zip Code)
who died on 16th day of November 2002
at Glens Falls Hospital 100 Park Street Glens Falls,NY 12801
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Bernard J.Lukaszewicz 104 River St., Hudson Falls,NY 12839
(Name) (Address)
Relationship to the deceased Son
Name of Funeral Home Carleton Funeral Home,Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has:no)
pacemaker in his or her body. (Circle One)
I 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 an demands for loss or damages which may be made against them
by reaso of or connected with the cremation of said remains as directed,
whether uch claims or demands are not wholly groundless, false or fraudulent.
68 Main Street P.O.Box 67, Hudson Falls,NY 12839
Witness) (Address)
` 'ver St. Hudson falls NY 12899
(Signat of elative or L gal Rep. and Address)
Signed on this date: 11/19/02