Healthcare Crematory Authorization Form

HEALTHCARE CREMATORY AUTHORIZATION FORM

Decedent Information

Full Legal Name:

Date of Birth:    Date of Death:    Sex:

Medical Record / Facility ID:    Attending Physician:

Authorizing Individual / Legal Representative

Authorizing Individual Address:

Phone:    ID Type/Number:

Funeral Home / Receiving Agent

Funeral Director Name:    License Number:

Insurance / Payment Information

Policy Number:    Group Number:    Subscriber Name:

Medical / Implant / Infectious Disease Information

HIV/AIDS    Hepatitis B    Hepatitis C    COVID-19    Other:

Pacemaker / ICD present: Yes    No

Removed prior to transfer    Not removed (I acknowledge removal may be required prior to cremation)

Authorization for Cremation and Disposition

I, the undersigned Authorizing Individual, certify under penalty of perjury that I am the person identified above and that I have the legal authority to direct disposition of the decedent's remains. I hereby authorize the funeral home or receiving agent named above to arrange for cremation of the decedent and to transfer the decedent to a licensed crematory for that purpose. I understand cremation is an irreversible process and that identification of the decedent prior to cremation will be conducted by the funeral home or named agent using the following method(s):

I authorize the crematory to perform standard processing including drying, high-temperature combustion, and mechanical processing of skeletal remains to produce cremated remains. I acknowledge that certain personal effects may be irretrievably altered or lost during cremation. I authorize the funeral home and crematory to remove pacemakers, defibrillators, prosthetics, and other devices if required for safety.

Retain cremated remains for pickup by funeral home or authorized agent    Ship cremated remains to:

Scatter remains at location designated by Authorizing Individual (if scattering by crematory, specify location):

Additional instructions or special handling for cremated remains:

Payment, Fees, and Personal Effects

I agree that any fees for cremation, transfer, temporary storage, transportation, and processing are my responsibility or the responsibility of the estate or payer listed above. I further acknowledge that all personal property accompanying the decedent has been inventoried and removed as noted below; unclaimed items left with the decedent may be retained or disposed of in accordance with applicable law and crematory policy.

Legal Acknowledgements, Releases, and Limitations

By signing below I release and hold harmless the funeral home, crematory, their agents, employees, and representatives from liability for loss or damage to personal effects or for actions taken in good faith reliance on this authorization. I acknowledge that the crematory will take reasonable measures to identify and protect the decedent and cremated remains, but that errors in identification or loss of cremated remains may occur despite reasonable care.

I certify that I have not been directed by a court order preventing cremation and that I will provide any required legal documentation upon request. I understand I may revoke this authorization in writing prior to the time the cremation process begins; revocation is ineffective once cremation has commenced.

HIPAA & Medical Information Release (Authorization)

I authorize the release of medical information and records related to the decedent's cause of death, infectious disease status, and any other information necessary to permit safe handling and cremation to the funeral home, receiving agent, and crematory named herein. This authorization is limited to information necessary for identification, public health reporting, and safe disposition.

I understand that this authorization will expire on the date indicated below or within sixty (60) days if no expiration date is provided. Authorization Expiration Date:

Certification and Sign-off

I certify under penalty of perjury that the information provided on this form is true and correct to the best of my knowledge. I have read and fully understand the statements, authorizations, and warnings contained in this document. I acknowledge that cremation is permanent and that I have been offered the opportunity to make alternate disposition arrangements.

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