,,GLOB” S.C. Jarosław Drejka, Maciej Drejka

,,GLOB” S.C. Jarosław Drejka, Maciej Drejka
Polska 06-200 Maków Maz. ul. Liliowa 11
tel./fax 0048-29-71-71-827 mobile +48-604-559-569 e-mail: [email protected]
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Place and date:
Authorization
I ……………………………………… authorize GLOB S.C. J.Drejka,
M.Drejka address Liliowa 11, 06-200 Maków Maz., Poland to arrange
and conduct the Repatriation ashes Mr./Ms ……………………………..…
from Poland to ……………………………..
I ……………………………………… authorize GLOB S.C. J.Drejka,
M.Drejka address: Liliowa 11, 06-200 Maków Maz., Poland to sign
any documents on my behalf.
Signed ……………………………………………...
Date ……………………
Relationship to Deceased – ………………………
Address
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(signature)