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5. PACEMAKERS, PAIN PUMPS, IMPLANTS, AND PROSTHESES.

Pacemakers, pain pumps, radioactive, silicon or other implants, mechanical devices or prostheses may create a hazardous condition when placed in the cremation chamber and subjected to heat.

The following list describes all devices (including mechanical, prosthetic, implants or materials) which may have been implanted in or attached to the Decedent: (Reference Section: B)

Description of Devices: _______________________________________________________________________________________________________________________________________

________

The remains of the Decedent do not contain any of the devices described in the above paragraph.

(Initials)

As Authorizing Agent, I instruct the Cremation Service Provider to remove each device listed above. Unless indicated directly below, the Cremation Service Provider/Crematory

________

is to dispose of all such devices.

(Initials)

________

The devices listed below are to be removed and returned to the Authorizing Agent:

(Initials)

____________________________________________________________________________________________________________________________________

6. RECYCLING OF METAL

Following the cremation process, the Crematory uses its best efforts to remove from the cremated remains non-combustible materials such as dental bridgework, implanted medical devices, and

metal hinges, latches, and nails from the cremation container. Typically, this non-combustible material is disposed of as waste. However, in the case of certain metals that are part of the device,

such as titanium, surgical stainless steel, cobalt, etc., third party companies will recycle this metal. With the express permission of the representative, this metal will be sent to a recycling

company. The representative understands that the Crematory is compensated by the recycling company for retrieving the metal and shipping it to the recycling company. All such compensation

paid to the funeral home shall be donated to a charitable organization. The representative authorizes the Crematory to take the following action, (Initial on the line next to your selected option).

________

Recycle any metal that is eligible for recycling and dispose of the remaining metal with the remainder of the non-combustible material.

(Initials)

________

Do not recycle the material. Instead, dispose of it with the remainder of the non-combustible material.

(Initials)

7. WITNESS OF CREMATION

Witnessing a cremation can be an emotional experience. Witnesses are assuming the risks involved and fully release the Cremation Service Provider and Crematory from any liability. To the

extent permitted by the Crematory, the persons listed below are authorized to be present at the cremation viewing room prior/during the cremation of the Decedent’s remains and during the removal

and processing of the cremated remains.

________

(List of Witnesses) ________________________________________________________________________________________________________________________

(Initials)

________

No Witnesses

(Initials)

8. THE CASKET OR ALTERNATIVE CONTAINER, THE CREMATION PROCESS AND THE URN OR TEMPORARY CONTAINER

As Authorizing Agent, I have read and understand the use of the casket or cremation container in Section C and I have selected the following casket or cremation container:

________

(Initials)

_______________________________________________________. I also understand that if the container selected is a rental casket, that embalming is required for health

concerns; that the rental casket has been used by at least one other client family; and that the deceased will be removed from the rental casket and placed in the cremation

container selected: _________________________________________________ prior to cremation.

________

As Authorizing Agent, I have read and understand the description of the cremation process contained in Section A and authorize the cremation processing and pulverization of

(Initials)

the remains of the Decedent. I further authorize the Cremation Service Provider to deliver the Decedent’s remains to the Crematory for the purposes of the cremation.

________

As Authorizing Agent, I have read and understand the use of the urn or temporary container in Section D and I have selected the following: urn or temporary container

(Initials)

________________________________________________________________________________________________________________ Personalized: Yes

❏

________

As Authorizing Agent, I give the Crematory permission to place a small amount of cremated remains in a keepsake urn:____________________________________selected

(Initials)

by the Authorizing Agent.

9. FINAL DISPOSITION

Following the cremation, the Authorizing Agent directs the Cremation Service Provider to undertake the actions set forth below to arrange the final disposition of the cremated remains of the

Decedent. If the cremated remains are shipped at any time, the Authorizing Agent directs that the Cremation Service Provider utilize registered U.S. mail with a return receipt or a shipping service that

uses an internal system for tracing the location of the cremated remains during shipment and requires a signed receipt of the person taking delivery of the cremated remains.

❏

Release to:

Name/Company: _____________________________________________________________________________ Relationship: _____________________________________

Address: _____________________________________________________________________________ Telephone: _______________________________________

Other: _____________________________________________________________________________________________________________________________

❏

__________________________________________________________________________________________________________________________________

The Authorizing Agent understands that if no arrangements for the final disposition, release or shipment of the cremated remains are made in this authorization, The Cremation Service Provider shall

hold the cremated remains for thirty (30) days after cremation. If during that thirty (30) day period the cremated remains are not retrieved by the person designated above to receive them or the

Authorizing Agent, or if arrangements for their final disposition are not made, the Cremation Service Provider may return the cremated remains to the Authorizing Agent at the address listed in

Section 3. In the alternative, if no arrangements for the final disposition of the cremated remains have been made within sixty (60) days after the cremation and if the Authorizing Agent has not taken

delivery of or caused the delivery of the cremated remains, or in the event the arrangements for the final disposition have not been carried out within that sixty (60) day period because of the inaction of

a party other than the Cremation Service Provider, then the Cremation Service Provider may dispose of the cremated remains in a grave, crypt or niche. The Authorizing Agent shall be liable for

the cost of such final disposition in a grave, crypt or niche and shall reimburse the Cremation Service Provider immediately upon receipt of an invoice.

Cremation Services, Policies, Procedures, Requirements And Authorizations - Northcoast Crematory Service Page 3

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