Form 12-Auth - Authorization To Accept Or Decline Embalming
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1AUTHORIZATION TO ACCEPT OR DECLINE EMBALMING
TO: ________________________________________
Treadway & Wigger Funeral Chapel
(Funeral Establishment Name)
RE: ________________________________________
(Decedent)
Embalming is the addition to, or the replacement of, body fluids by chemical
preservatives or the application of chemical preservatives for the temporary
preservation of the body. I understand that embalming is not required by law.
I, ____________________________, do __ do not __ (check one) request embalming.
I understand that for storage or embalming purposes the decedent may be transported
to the following location:
______________________________________________________________________
(Location Name and Address)
The undersigned hereby represents that he/she has the legal right to control disposition
of the remains of the decedent.
Signed: ____________________________, Relationship to Decedent: _____________
Executed this ____ day of _______________, _____, at ________________________.
2016
(Month)
(Year)
(City and State)
This section is to be completed by the funeral establishment if authorization to accept or
decline embalming is obtained orally.
The above statement regarding embalming and storage was read and/or provided to
______________________________, Relationship to Decedent: _______________,
who did __ did not __ (check one) authorize embalming at the above named funeral
establishment. Telephone Number: _________________________
Date and time authorization granted: ______________________________
This section is to be completed by the funeral establishment representative who is
executing this authorization to accept or decline embalming.
I declare under penalty of perjury that the foregoing is true and correct.
Executed this ____ day of _______________, _____, at ________________________.
2016
Napa, California
(Month)
(Year)
(City and State)
________________________________
________________________________
Funeral Establishment Representative (Print Name)
Funeral Establishment Representative (Signature)
12-AUTH (rev. 11/14)
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Parent category: Legal