Dos-1898-F-L - Authorization For Cremation And Disposition Page 3
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3(Initial the following)
_______ I/We understand that if the remains are not claimed within 120 days of cremation,
_______________________________________ may dispose of the remains in an irretrievable manner,
(crematory name)
such as by scattering.
CREMATION CONTAINER/URN
(Initial ONE of the following)
_______ An urn to be used as a container for the cremated remains has been purchased from
______________________________________ and is described as follows:
________________________________________________________________________.
I/We understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be
used for delivery.
-OR-
_______ An urn has not yet been purchased. I/We understand that if no urn is purchased or otherwise provided
_______________________________________ will place the cremated remains in a rigid temporary
(crematory name)
container for delivery.
This Authorization Form was provided by
_____________________________________________,
(funeral director name)
was executed at
__________________________________________________________________,
(funeral home name)
_________________________________________________ and is signed by the funeral director
(funeral home address)
as witness to its execution.
I/We have received a completed copy of this Authorization Form.
The person(s) identified below is/are the person(s) in control of disposition, who by signing this
Authorization Form, attest(s) to the accuracy and completeness of the information contained in this
Authorization Form and authorize(s) the foregoing.
Signed this _____________ day of _____________________, 20_____.
Typed or Printed Name
Signature
Address
Typed or Printed Name
Signature
Address
Typed or Printed Name
Signature
Address
WITNESS:
Funeral Director Signature
Funeral Director Typed or Printed Name
Registration Number
DOS-1898-f-l (Rev. 01/10)
Page 3 of 3
Name of Deceased
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