Authorization For Cremation And Disposition Of Human Remains printable pdf download

AUTHORIZATION FOR CREMATION AND DISPOSITION OF HUMAN REMAINS

__________________________________________

(Name of Crematory)

______________________________

(Address of Crematory)

______________________________

Phone: _______________ Fax: __________________

Cremation Number____________

I (We), the undersigned (Authorizing Agent(s)), hereby authorize _____________________________________________

________________________________________________________________________ (Funeral Home, City, and State)

and _________________________________________________________________ (Crematory) to cremate the human

remains of the Decedent named below in accordance with the provisions set forth in this document and all applicable

laws, rules, and regulations. I (We) have identified the human remains that were delivered to the funeral home as the

Decedent and have authorized the Funeral Home to deliver the decedent to the Crematory.

IDENTIFICATION

Name of Deceased: ________________________________________________ Sex: ____________ Age: _______

Date of Death: _______________ Place of Death: _____________________________________________________

PRENEED CREMATION ARRANGEMENTS

Did the decedent arrange for his or her own cremation, on a preneed basis?

Yes ___ No ___

Did the decedent leave a will with written instructions to be cremated?

Yes ___ No ___

Did the decedent leave oral instructions to be cremated?

Yes ___ No ___

If yes, with whom: ____________________________________

Did the decedent arrange for final disposition of the cremated remains?

Yes ___ No ___

If yes, please describe: _________________________________________________________________________

PACEMAKERS, PROSTHESIS, SILICON, AND RADIOACTIVE IMPLANTS

Mechanical, radioactive devices or implants may create a hazardous condition when placed in the cremation chamber.

Please list all existing devices or implants that should be removed prior to cremation:

__________________________________________________________________________________________________

____________________________________________________________________________________________

WITNESSING

Are there any people who wish to witness the casket or container being placed in the cremation chamber?

Yes ___ No ___ If yes, please provide names: ____________________________________________________________

_____________________________________________________________________________________________

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Authorization For Cremation And Disposition Of Human Remains