Healthcare Cremation Permission Form

Healthcare Cremation Permission Form

Decedent Information

Authorized Requester / Next of Kin

I affirm that I am the person legally authorized to direct disposition of the decedent's remains under applicable law and that the information provided in this form is true and correct to the best of my knowledge. If not the next of kin, I have attached documentation evidencing my authority.

Legal Authority (check applicable)

Next of kin
Surviving spouse
Executor or Administrator (attach letters testamentary or court documents)
Health care agent under durable power of attorney (attach document)
Court-appointed guardian or legal representative (attach documentation)
Other (describe below)

Funeral Home / Crematory Information

Disposition of Cremated Remains

Indicate how the cremated remains are to be handled. If multiple boxes are checked, the facility will follow the most recent written instruction provided by the legally authorized person.

Return remains to the named funeral home above
Release remains to named person:
Scatter remains (provide location instructions below)
Retain cremated remains for burial at later date
Ship remains out of state (provide destination and shipping agent below)
Other (describe below)

Organ and Tissue Donation

Yes, organs/tissues were donated prior to death and may be subject to separate authorizations
No, no organ/tissue donation was arranged
Unknown

Authorization and Release

I, the undersigned, hereby authorize the cremation of the remains of the decedent identified above. I acknowledge that cremation is an irreversible process and that identification and recovery of all prosthetic devices, surgical implants, or personal effects cannot be guaranteed. I authorize the removal of medical devices and surgical implants as necessary for cremation.

I certify under penalty of law that I am the person legally entitled to authorize cremation or that I have provided documentation that establishes my legal authority. I release and hold harmless the facility, its employees, agents, funeral home, and crematory from liability for carrying out this cremation and disposition instruction in reliance upon this authorization and any attached documentation.

Fees, Payment and Indemnity

I acknowledge that I am responsible for all cremation, handling, transportation, storage, and related fees charged by the funeral home and crematory unless invoiced and paid by another party. I understand any outstanding charges must be paid prior to release or shipment of cremated remains. I agree to indemnify and hold the facility harmless for claims arising from my representations of authority or my instructions.

Payment method: Cash Card Insurance/Third party Other:

HIPAA and Release of Records

I authorize release of decedent's medical records and portions thereof necessary to complete cremation and death certification, to the funeral home, crematory, coroner/medical examiner, and other authorized agents. I acknowledge that this authorization complies with applicable privacy law authorizing disclosure for disposition of remains and is valid as provided herein.

I acknowledge and authorize release of medical information as described above.

Personal Effects and Hazardous Materials

I certify that to my knowledge there are no implants or foreign materials that create a hazard during cremation other than those described above. I agree to indemnify the facility for any damage or injury resulting from undisclosed hazardous materials.

Attending Physician / Pronouncement

The attending physician or medical examiner shall certify cause of death and clearance for cremation as required by law. The facility will not proceed with cremation until any required medical or legal releases are received.

Acknowledgement and Certification

By signing below I certify: (1) I have full authority to direct disposition of the decedent's remains or have attached documentation granting such authority; (2) the information I have provided is true and accurate; (3) I understand cremation is irreversible; (4) I have read, understood, and accept the terms, fees, and releases set forth in this form.

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