Fill and Sign the Cremation Certificate Form

Certificate as Disposition of Cremated Body State of ________________ (name of state) County of _________________ (name of county) P ERSONALLY appeared before me, the undersigned authority in and for said county and state, _________________ (Name of Affiant) , who, having been being first duty sworn by the undersigned Notary Public, deposes and says: 1. I, _________________ (name of funeral director) , of ____________________ _________________________________________________________ (street address, city, state, zip code) , a funeral director whose principal place of business is at ____________________________________________________________________ __________ (street address, city, state, zip code) , certify that I was called to take charge of the deceased body of __________________ (name of decedent) , late of ______________________________________________________________________ (address of decedent) , who died on ___________________ (date of death) . 2. I prepared ______ (his or her) body and placed it in a casket. 3. On _________________ (date of cremation) , the body was cremated in the ______________________ (name of crematory) at ___________________________ _______________________________________________ (street address, city, state, zip code) , and s hipped for burial to the _______________________ (Name of Cemetery) at __________________________________________________________ ________________ (street address, city, state, zip code) . ___________________________________ (Printed Name of Affiant) ___________________________________ (Signature of Affiant) SWORN to and subscribed before me, this the ____ day of _______________, 20____. _____________________________ NOTARY PUBLIC My Commission Expires: ___________________