Healthcare Cremation Disclosure

HEALTHCARE CREMATION DISCLOSURE

Facility Name:

Patient / Decedent Information

Authorized Person / Next of Kin

Authorization and Acknowledgment

I, , hereby authorize Facility Name: and the designated crematory to cremate the human remains of the decedent named above and to process and dispose of the cremated remains in accordance with my written instructions and the policies of the facility and crematory.

I understand and acknowledge that cremation is an irreversible process, that the cremation process will reduce the remains to fragments, and that complete recovery of all fragments may not be possible. I further acknowledge that any personal property not claimed or not identified on this form may be removed prior to cremation. I understand that certain implanted medical devices, including but not limited to pacemakers, must be removed prior to cremation and that removal and lawful disposal of such devices will be performed.

Options (select applicable items)

Allow viewing of the decedent prior to cremation, subject to facility policy and local law.

Request private family witness at the time of placement into cremation chamber (subject to availability and facility policy).

Authorize removal of implanted devices and prostheses that may present hazard or interfere with cremation. I authorize their disposal in accordance with law and facility procedure.

Authorize retention of small tissue or bone samples for required identification, testing, or pathology for a period determined by the facility or crematory.

Return cremated remains to authorizing agent for private disposition.

Scatter or inter cremated remains by facility/crematory in a manner consistent with facility policy and local regulations.

Place cremated remains in temporary custody of facility for a specified period (see special instructions).

Identification, Verification, and Alternatives

The facility will affix an identification tag to the decedent and maintain chain of custody records. Prior to cremation, identification will be verified as required by law and facility procedure. If identification cannot be verified, cremation may be delayed until verification is complete. Alternatives to cremation (such as burial or donation) were explained and considered.

Revocation / Expiration

This authorization may be revoked by the authorizing person by delivering written notice to the facility before the physical transfer of the decedent to the crematory begins. I understand that revocation may not be possible once cremation has begun. Authorization expiration date:

Fees, Liability, and Release

I acknowledge that charges may apply for removal of implanted devices, special handling, or alternate disposition requests, and that such charges are the responsibility of the authorizing person or estate. I release and agree to hold harmless the facility, its employees, agents, and the crematory from liability for loss or damage to personal property not identified or for any action taken in reasonable reliance on this authorization, except for gross negligence or intentional misconduct.

I certify under penalty of law that I am the person authorized to sign for disposition of the decedent under applicable law and that the information provided on this form is true and correct to the best of my knowledge.

Initial here to confirm you have read and understand the foregoing statements:

Certification of Identity / Legal Authority

I certify that I am the person named above or the legally authorized representative of the decedent. If signing as a representative, specify the basis of authority:

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