Authorization For Cremation And Disposition Of Human Remains Page 3

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LIMITATION OF LIABILITY
To the extent provided by Tennessee Code Annotated Sections 62-5-107 and 62-5-511, I (we) agree to indemnify and
hold the Crematory harmless from any loss, damages, or liability concerning the failure to correctly identify the remains
of the Decedent, disclose the presence of any implanted mechanical or radioactive devices, or final disposition of the
remains of the Decedent.
SIGNATURE OF AUTHORIZING AGENTS
THIS IS A LEGAL DOCUMENT. CREMATION IS IRREVERSIBLE AND FINAL.
READ ALL PORTIONS OF THIS DOCUMENT CAREFULLY BEFORE SIGNING.
By executing this Cremation Authorization Form, as Authorizing Agent(s), I (we) warrant that all representations and
statements contained in this form are correct and true, and that I (we) have read and understand all the provisions
contained in this form.
Name: ________________________________________ Signature: ___________________________________________
Relationship: ________________________________________ Date: __________________________________________
Phone Number: ___________________ Address: _________________________________________________________
__________________________________________________________________________________________________
Name: ________________________________________ Signature: ___________________________________________
Relationship: ________________________________________ Date: __________________________________________
Phone Number: ___________________ Address: _________________________________________________________
__________________________________________________________________________________________________
Name: ________________________________________ Signature: ___________________________________________
Relationship: ________________________________________ Date: __________________________________________
Phone Number: ___________________ Address: _________________________________________________________
__________________________________________________________________________________________________
Name: ________________________________________ Signature: ___________________________________________
Relationship: ________________________________________ Date: __________________________________________
Phone Number: ___________________ Address: _________________________________________________________
__________________________________________________________________________________________________
____________________________________________________________________________________________
License #
State
Signature of Funeral Director as Witness for Authorizing Agent(s) Signature(s)
Date
REPRESENTATION OF FUNERAL DIRECTOR
I warrant, to the best of my knowledge, that I have reviewed this form with the Authorizing Agent(s), that no member of
the funeral home has any knowledge or information that would lead us to believe that any of the answers provided by
the Authorizing Agent(s) are incorrect, that the human remains delivered to the Crematory and represented as the
human remains of the Decedent is the Decedent, that our Funeral Home obtained all necessary permits authorizing the
cremation and those permits are attached, and the representations concerning a pacemaker or other implants are true.
Signature: __________________________________________________ Date: __________________________________
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