Healthcare Cremation Bundle

HEALTHCARE CREMATION BUNDLE

This Cremation Authorization and related consents constitute a legally binding authorization for the handling, disposition, and release of a deceased individual’s remains. The person signing below represents that they are the legally authorized representative or next of kin and have the authority to execute this Authorization. All references to "Facility," "Crematory," or "Provider" include its agents and employees.

Decedent / Patient Information

Date of Birth:    Date of Death:

Authorized Representative / Requesting Party

Relationship to Decedent:

Phone:    Email:

Cremation Authorization and Instructions

By signing this document, Requesting Party hereby authorizes the Facility and its designated Crematory to perform cremation of the remains of the decedent identified above and to take necessary preparatory actions including transportation, refrigeration, removal of medical devices, and completion of required documentation. This authorization includes:

• Authorization to cremate and dispose of tissues not intended for donation or return.
• Authorization to remove medical devices (including pacemakers and defibrillators) for safety prior to cremation.
• Authorization to release cremated remains in accordance with the instructions below.

Direct cremation (no viewing)    Cremation with viewing    Witnessed cremation (arrange time)    Memorial service (facility to coordinate)

Provide urn/container description or select provider-supplied container:

Delivery method (select one):    Release to Requesting Party for pickup    Mail to address on file    Scatter at specified location    Interment at cemetery

Medical and Donation Information

Organ or tissue donation status: Donor registered / donation occurred    No donation

Was an autopsy performed? Yes    No

Personal Effects and Retained Items

Personal items removed prior to cremation shall be handled as follows (select one or describe):    Return to family    Dispose of items    Hold for pickup by designated agent

Fees, Authorizations and Acknowledgments

Requesting Party authorizes Facility to obtain payment for cremation services and related charges. The Facility may rely upon this Authorization as evidence of authority to proceed and to charge fees as indicated. Any additional charges incurred for special handling, required permits, or regulatory compliance shall be the responsibility of the Requesting Party unless otherwise agreed in writing.

Legal Release, Indemnity and Certification

The Requesting Party certifies under penalty of perjury that they are legally authorized to direct disposition of the decedent's remains. The Requesting Party releases, indemnifies, and holds harmless Facility, Crematory, its agents, employees, and representatives from any claim, loss, liability, or expense arising from reliance on this Authorization or from actions taken in good faith pursuant hereto, including but not limited to claims by other family members or third parties asserting superior rights to control disposition.

If this Authorization conflicts with a valid, prior written directive executed by the decedent or a court order, the Facility must comply with such directive or order. The Requesting Party agrees to notify Facility promptly if they become aware of any such conflict.

HIPAA / Medical Records Authorization

Authorization is granted to release medical records, cause of death information, and other protected health information of the decedent to the Facility, Crematory, and associated agents for the limited purpose of completing cremation permits, death certificates, and compliance with legal and regulatory requirements. This Authorization shall remain effective until the expiration date set below or until revoked in writing, provided that revocation will not affect disclosures already made in reliance on this Authorization.

Authorization expiration date:

Special Requests / Additional Authorizations

By signing below, Requesting Party acknowledges they have read and understood this Authorization in full, have had the opportunity to ask questions, and authorize the Facility and Crematory to act in accordance with the selections and instructions provided herein. This document may be executed electronically or in counterparts, each of which shall be deemed an original.

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