Healthcare Cremation Authorization

HEALTHCARE CREMATION AUTHORIZATION

Decedent Name:    Date of Birth:

Date of Death:    Time of Death:    Place of Death:

Authorizing Person

Funeral Service / Facility

Authorization and Legal Acknowledgments

I, the undersigned authorizing person identified above, hereby authorize the above-listed facility and any authorized crematory agents to perform cremation of the decedent named above. I represent that I have the legal authority to authorize cremation and that all information provided on this form is true and complete to the best of my knowledge. I understand that once cremation is performed, certain human remains are irrevocably altered and permanent identification of tissues will not be possible.

I authorize the release of medical information and medical records necessary to complete required death certifications and cremation permits. I understand that completion of the cremation may be delayed if the medical examiner, coroner, or other legal authority asserts jurisdiction.

Type of Cremation Services Requested

Direct cremation (no public viewing or funeral service prior to cremation)
Cremation following viewing/ceremony at facility (describe below if special instructions)
Cremation following formal service or memorial (facility to coordinate)

Medical Devices, Implants, and Tissue/Organ Donation

Pacemaker/Implanted Device Removal: I authorize removal of pacemaker or other implanted devices for safe cremation and proper handling of remains; I understand removal is typically required to prevent hazard.
Organ/Tissue Donation: Decedent was registered as an organ/tissue donor or donation has been arranged. No organ/tissue donation occurred or no arrangement exists.

I understand that certain medical or research specimens may be retained by medical providers and that cremation may be delayed to allow for release of specimens where legally required.

Handling of Personal Property and Prosthetics

Personal Effects: I direct that any personal property accompanying the decedent be returned to the authorized person listed on this form unless otherwise indicated below.

Prosthetics and Non-organic Medical Devices: I understand some devices may be retained, removed, recycled, or destroyed as part of the cremation process. I authorize the facility and crematory to determine appropriate handling for these items.

Disposition of Cremated Remains

Preferred disposition (check one or specify below):
Return cremated remains to authorizing person/facility
Scatter remains on private property as directed by authorizing person
Scatter at sea in accordance with applicable regulations
Inurnment/interment in cemetery or columbarium (provide location below)

Privacy and Release

I acknowledge receipt of the facility's privacy practices and authorize release of decedent medical information to the funeral home, crematory, and any governmental authority for the purpose of completing death certificates, cremation permits, and disposition documentation.

I understand that if a legal authority (such as a medical examiner or coroner) requires retention of the body for investigation, the cremation may be delayed or prohibited until legal clearance has been provided.

I acknowledge and consent to the statements above regarding privacy, release of records, and potential delays due to legal or medical examiner jurisdiction.

Indemnification and Certification

By signing below I certify that I am the person authorized to make decisions concerning the disposition of the decedent's remains and that I have provided accurate information regarding authority and next of kin. I agree to indemnify and hold harmless the funeral home, crematory, and their agents from any claims, liabilities, or expenses that may arise from reliance upon this authorization, except where caused by gross negligence or willful misconduct of the facility.

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