Cremation Authorization Form

CREMATION AUTHORIZATION FORM

RECITALS

WHEREAS, Client Name: is the lawful next of kin or legally authorized representative of the decedent identified below; and

WHEREAS, Crematory Name: is a duly licensed cremation services provider and has agreed to provide cremation and related disposition services under the terms set forth in this form; and

WHEREAS, Client hereby authorizes Crematory to perform cremation and related services for the decedent in accordance with the instructions, terms, and conditions contained in this Cremation Authorization Form.

DECEDENT INFORMATION

Date of birth:    Date of death:

AUTHORIZED AGENT / NEXT OF KIN

Relationship to decedent:    Phone:

AUTHORIZATION TO CREMATE / SPECIAL PROCEDURES

I hereby authorize Crematory Name: to cremate the remains of the decedent and to perform customary ancillary services, including removal of medical devices and processing of cremated remains, subject to the instructions below and to all applicable laws and regulations.

Please select applicable authorizations and instructions:

I expressly authorize cremation of the decedent's remains.
I authorize removal of pacemaker, defibrillator, or other implanted devices prior to cremation (recommended).
Decedent was an organ/tissue donor; disposition of unembalmed tissue and organs must comply with applicable medical examiner/organ procurement procedures.
Retain remains for autopsy or investigation as directed by medical or legal authority.

SCOPE OF WORK

The cremation services to be provided by the crematory include receipt and identification of the decedent, preparation of necessary permits and documentation, transportation within facility service area, placement in a cremation container, conducting cremation in an appropriate retort, subsequent processing of bone fragments to a recognizably cremated state, and delivery or release of cremated remains in accordance with the disposition instructions set forth in this form. Any deviation from these services must be authorized in writing by the authorizing agent.

PAYMENT TERMS

The authorizing agent agrees to pay the crematory the fees and charges set forth below. Fees are due according to the schedule below; unpaid balances shall accrue the stated late fee until paid in full.

Balance due by:    Late fee after due date:

Accepted forms of payment:  Cash  Check  Credit/Debit Card (processed in person)

TERM AND TERMINATION

This authorization is effective on the date signed by the authorizing agent and remains in effect until the cremation is completed and cremated remains are delivered or otherwise lawfully disposed, unless earlier revoked as provided below.

Effective date of authorization: . This authorization will expire on: unless otherwise extended in writing.

Termination by authorizing agent requires written notice delivered to the crematory no later than days prior to the scheduled cremation; termination does not relieve the authorizing agent of obligations for costs already incurred, including but not limited to refrigeration, transport, and permit fees.

CONFIDENTIALITY

The parties agree to maintain the confidentiality of all personal and medical information obtained in connection with these services and to disclose such information only as required by law, as necessary to perform the services described herein, or with the express written consent of the authorizing agent. The crematory may provide necessary information to government agencies, medical examiners, or other parties legally entitled to receive it.

DISPOSITION OF CREMATED REMAINS

Select the desired disposition of cremated remains:

Return to authorizing agent or representative for final disposition
Scattering (if permitted by law)
Burial of cremated remains
Donation for memorial or scientific purposes
Hold at facility for pickup or later shipment

IDENTIFICATION AND WITNESSING

Identification provided by authorizing agent: ID type , ID number , Issuing state/country .

RELEASE, INDEMNIFICATION, AND LEGAL NOTICE

The authorizing agent represents and warrants that they are the lawful next of kin or otherwise have legal authority to authorize cremation. The authorizing agent releases and holds harmless the crematory, its employees, and agents from any claims arising from the performance of cremation and disposition in accordance with this authorization, except for claims arising from willful misconduct or gross negligence. The authorizing agent agrees to indemnify the crematory for any costs, expenses, or damages arising from misrepresentations of authority or inaccurate information provided on this form.

The crematory shall exercise reasonable care in performing services but is not responsible for the condition of remains or medical implants that cannot be detected or removed, or for damages resulting from causes beyond its control. If a medical examiner or coroner requires further procedures or retains jurisdiction, cremation will not proceed without legal clearance.

GOVERNING LAW; ENTIRE AGREEMENT

This Authorization shall be governed by and construed in accordance with the laws of the state in which the crematory is located. This form, together with any written addenda signed by both parties, constitutes the entire agreement between the parties concerning the cremation and disposition of the decedent and supersedes all prior oral or written agreements.

CERTIFICATION BY AUTHORIZING AGENT

I certify under penalty of law that the information supplied on this form is true and correct to the best of my knowledge and that I have the legal authority to authorize cremation and disposition of the decedent's remains as indicated above.

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