Healthcare Cremation Application

HEALTHCARE CREMATION APPLICATION

Facility Name:    Facility Phone:

Decedent Information

Date of Birth:    Date of Death:    Sex:

Location and Attending Clinician

Medical Examiner / Coroner Notified: Yes No

Applicant (Authorizing Agent)

Legal Authority (Select applicable)

I certify that I am the person authorized under applicable law to direct disposition of the decedent's remains. Check the box that describes your legal authority:

Spouse    Adult Child    Parent    Sibling    Court-appointed Legal Representative / Guardian    Executor / Personal Representative   

Organ / Tissue Donation

Was the decedent a registered organ/tissue donor? Yes No

If yes, indicate any restrictions or special handling required for donation or retrieval:

Cremation and Disposition Instructions

I request that the decedent be cremated and direct the disposition of cremated remains as follows (select one or more and provide details):

Return cremated remains to applicant    Retain at facility for collection    Private scattering by applicant/designee    Burial of cremated remains    Ship cremated remains (requires shipping address)

Medical Device and Personal Property Handling

I authorize the removal of implanted medical devices, pacemakers, defibrillators, and other items that may pose a hazard during cremation, and acknowledge these items may be retained, destroyed, or disposed of in accordance with facility policy.

Consent to device removal: Yes No

Fees, Liability, and Acknowledgments

I acknowledge that all applicable cremation and disposition fees are payable in accordance with the facility's terms and that the facility may require payment prior to release or shipping of cremated remains. I further understand that cremation is an irreversible process and that the facility is authorized to proceed unless prohibited by the medical examiner or other legal authority.

Release and indemnification: To the fullest extent permitted by law, I release the facility, its employees, agents, and contractors from liability for actions taken in good faith in reliance upon this authorization, and agree to indemnify and hold harmless the facility for claims arising from errors in the information provided or from actions taken pursuant to this authorization.

Certification and Authorization

I certify under penalty of perjury that the information provided in this application is true and correct and that I have the legal authority to authorize cremation and disposition of the decedent's remains as indicated. I understand that misrepresenting my authority may subject me to civil or criminal penalties.

This authorization includes consent for necessary transport, care, and preparation of the decedent for cremation, including but not limited to removal of medical devices, temporary storage, and disposition of cremated remains in accordance with my instructions above and applicable law.

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