Sample Cremation Authorization Form printable pdf download

SAMPLE CREMATION AUTHORIZATION FORM

This is a legal document. It contains important provisions concerning cremation. Read this

document before signing.

The undersigned (the “Authorizing Agent”), hereby authorize and request ***Funeral Home***, in accordance and

subject to its rules and regulations, and any applicable state or local laws or regulations, to cremate the human remains

of_____________________________________________, (the "decedent"), who died on the following date

___________________ at the following location__________________________________________________ from the

following cause______________________________.

IDENTIFICATION

...

I, the Authorizing Agent, wish to identify the human remains specified above, or approve my next of kin to do so, prior

to cremation.

...

I, the Authorizing Agent, elect to waive my right to identify the human remains specified above, or my next of kin to

do so, prior to cremation.

LIMITATION OF LIABILITY

As the Authorizing Agent, I hereby agree to indemnify and hold harmless ***Funeral Home***, its officers, agents,

employees of and from any and all claims, demands, causes or causes of action, and suits of every kind, nature and

description, in law or equity, including legal fees, costs and expenses of litigation, arising as a result of, based upon or

connected with this authorization, including the failure to properly identify the decedent or the humans remains, the

processing, shipping and final disposition of the decedents cremated remains, the failure to take possession of or make

proper arrangements for the final disposition of the cremated remains, any damages due to harmful or explodable

implants, claims brought against any other person(s) claiming the right to control the disposition of the decedent or the

decedent's cremated remains, or any other action performed by the crematorium, its officers, agents, or employees,

pursuant to this authorization, excepting only acts of willful negligence. The liability of the ***Funeral Home*** shall be

limited to the cremation of the decedent. No warranties express or implied are made and damages shall be limited to the

amount of the cremation fee paid.

PACEMAKERS, PROSTHESIS, SILICON AND RADIOACTIVE IMPLANTS

I, the undersigned, state that the decedent's remains do not contain a pacemaker, prosthesis, silicon implants, radioactive

implant or any other devise that could be explosive or harmful to the crematorium. If such a devise exists, I have

instructed the funeral director to arrange for the removal of these devises and to properly dispose of them prior to

cremation. I agree that in the event of my failure to notify the funeral home of the existence of any of the referenced

devises, I will be liable for damages to the crematorium or injury to crematorium personnel.

CHECK IF THE FOLLOWING ARE PRESENT: PACEMAKER PROSTHESIS SILICON IMPLANTS

OTHER IMPLANT DNA PRESERVATION

I wish to have ***Funeral Home*** extract a small tissue sample at the time of death for the purpose of DNA

Preservation: YES NO

DISCLOSURES REGARDING THE CREMATION PROCESS

It is our policy to provide information concerning the cremation process so that our client families and friends are fully

informed. These disclosures are provided in the interest of satisfying any questions and allaying any concerns you may

have. The cremation, processing and disposition of the decedents remains will be performed in accordance with New

Hampshire Revised Statutes Annotated 325-A, New Hampshire Code of Administrative Rules Chapter He-P 600, and any

and all other governing rules and the policies, procedures and requirements of ***Funeral Home***. Cremation will only

take place after all of the following conditions have been satisfied: (a) all scheduled ceremonies and viewing have been

Sample Cremation Authorization Form