Authorization For Cremation And Disposition Form printable pdf download

County Approval

PCI

No.______________

7350 State Road • (215) 708-7747 • Fax (215) 708-8022 • Philadelphia, PA 19136 •

AUTHORIZATION FOR CREMATION AND DISPOSITION

(Please print or type)

I(We), the undersigned (the “Authorizing Agent(s)”), hereby authorize and request P.C.I., in accordance with and subject to its rules and regulations, and any

applicable state or local laws or regulations,

to cremate the human remains of

(the “decedent”)

and to arrange for the final disposition of the cremated remains, as set forth on this form.

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I(We)

have identified

the human remains that were delivered to the funeral home as the decedent, or I(we) am(are) willing to accept the signature of the

Medical Examiner/Coroner's Office stating that the deceased has been positively identified by that office and released by that office to the appropriate funeral home.

And I(we) have authorized the funeral home to deliver the decedent to P.C.I., for cremation.

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I(We) have read the attached document entitled “P.C.I. Policies, Procedures and Requirements,” and hereby authorize P.C.I. to perform the cremation of the

decedent in accordance with that document. (Reverse side of this document)

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IDENTIFICATION

Date of Death__________________________ Time of Death_________ AM / PM

Sex_________ Race____________________________ Age_________

Place of Death: City, Borough, Twp._______________________________________________ County___________________________ State______________

Est. Date/Time of Receipt by P.C.I. _________________________________Casket/Cremation Container____________________________________________

PACEMAKERS AND RADIOACTIVE IMPLANTS / SEEDS MAY BE DANGEROUS WHEN PLACED IN A CREMATION CHAMBER

AND MUST BE REMOVED PRIOR TO DELIVERING THE DECEDENT TO P.C.I.

Please initial ONE of the next two paragraphs. (for pre-arrangement, answer as of current status)

do not contain

The decedent’s remains

a pacemaker, radioactive implant or any other device that could be harmful to the crematory. They are safe to cremate.

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The decedent’s remains

contain a pacemaker, radioactive implant or other device that could be harmful to the crematory.The following list contains all existing

devices (including all mechanical, radioactive implants and prosthetic devices) which are implanted in or attached to the decedent, that should be removed prior to

cremation.________________________________________________________________________________________________________________________

I have instructed the funeral home to remove or arrange for the removal of these devices and to properly dispose of them prior to transporting the decedent to P.C.I.

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PACKAGING AND FINAL DISPOSITION

Cremated Remains Receptacle(s) _____________________________________________________________________________________________________

(Specific

instructions)______________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________

After the cremation has taken place, the cremated remains have been processed and the processed cremated remains placed in the designated receptacle(s),

P.C.I. will arrange for the disposition of the cremated remains as follows, and the Authorizing Agent(s) hereby authorizes P.C.I. to package and release, deliver or

transport the cremated remains as specified. Check one of the following:

1._____ Deliver the cremated remains to the funeral home by: (date and time)__________________________________________________________________

2._____ Release the cremated remains to the funeral home to be picked up at P.C.I. by: (date and time)_____________________________________________

3._____ Release the cremated remains to P.C.I. for South Jersey Sea Scattering Service.

4._____ Release the cremated remains to P.C.I. to consign to earth.

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AUTHORITY OF AUTHORIZING AGENT

I(we),

the undersigned, hereby certify that I am the closest living next of kin of the decedent and that I am related to the decedent as his/her,

________________________ or that I otherwise serve (served) in the capacity of _________________________________________to the decedent, that I have

charge of the remains of the decedent and as such possess full legal authority and power, according to the laws of the state of____________, to execute the

authorization form and to arrange for the cremation and disposition of the cremated remains of the decedent. In addition, I am aware of no objection to this crema-

tion by any spouse, child, parent or sibling.

LIMITATION OF LIABILITY

As the Authorizing Agent(s), I(We) hereby agree to indemnify, defend, and hold harmless P.C.I., its officers, agents and 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 any 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 human remains transmitted to

P.C.I., the processing, shipping and final disposition of the decedent’s cremated remains, the failure to take possession of or make proper arrangements for the

final disposition of the cremated remains, any damage due to harmful or explodable implants, claims brought by 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 P.C.I., its officers, agents, or employees, pursuant to this

authorization, excepting only acts of willful negligence.

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SIGNATURE OF AUTHORIZING AGENT(S)

THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL.

READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.

By executing this Cremation Authorization Form, as Authorizing Agent(s), the undersigned warrant that all representations and statements contained on this form

are true and correct, that these statements were made to induce P.C.I. to cremate the human remains of the decedent, and that the undersigned have read and

understand the provisions contained on this form.

Executed at ______________________________________________________________________ this _______________ day of ______________________________, 20_________

Name ___________________________________________________________________________

Signature __________________________________________________________

Relationship to Decedent ___________________________________________________________ Phone No. (_______________)_________________________________________

Address____________________________________________________________________________________________________________________________________________

Name ___________________________________________________________________________ Signature __________________________________________________________

Relationship to Decedent ___________________________________________________________ Phone No. (_______________)_________________________________________

Address____________________________________________________________________________________________________________________________________________

Name and Address of arranging Funeral Home_____________________________________________________________________________________________________________

Signature of Funeral Director as Witness for Signature(s) of Authorizing Agent(s)___________________________________________________________________________________

Rev. 07.14

WHITE: PCI

YELLOW: Authorizing Agent

PINK: Funeral Home

Authorization For Cremation And Disposition Form

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