Kentucky Cremation Authorization Form

PRE-NEED CREMATION AUTHORIZATION FORM

COMMONWEALTH OF KENTUCKY

OFFICE OF THE ATTORNEY GENERAL

CR-3, #11-02

NMS, INC.

CARE CREMATION SERVICE

1014 EASTLAND DRIVE

LEXINGTON, KY 40505

Phone (859)388-9442    Fax (859)388-9443

In making a pre-need authorization for the cremation of your remains, you are the authorizing agent. Please read carefully the items below. In the statement titled Final Disposition you must indicate your desire pertaining to the disposition of your cremated remains. After you have read and completed each item, your signature is required on the item titled Signature of Authorizing Agent.

IDENTIFICATION

(Please Print All Information On This Form)

Name:

Address:

City, State, Zip:

Home Telephone: ( )

Age: Sex:

Does the Decedent Authorizing Agent have any infectious or contagious disease? YES NO

If yes, please explain:

Mechanical or radioactive devices or implants in the Authorizing Agent may create a hazardous condition when placed in a cremation chamber.

Does the Decedent Authorizing Agent's body contain a pacemaker, prosthesis, radioactive implant, or any other device that could be explosive? YES NO

If any such device(s) exist, the next class of authorizing agent is responsible for disclosing their existence at the time of death.

Has the Decedent Authorizing Agent been treated with therapeutic radionuclides such as Strontium 89 or any other treatment that would result in residual radioactive material remaining as part of the Decedent Authorizing Agent's remains? YES NO

If yes, what was the treatment:

Date treatment was last administered:

The Decedent Authorizing Agent shall carefully read and understand the following statements before signing this authorization. The decedent authorizing agent shall complete the segment directing the final disposition of his/her cremated remains. CARE CREMATION SERVICE will not conduct any cremation nor accept a body for cremation unless it has a cremation authorization form signed by the Decedent Authorizing Agent clearly stating the final disposition.

1. All cremations are performed individually. It is unlawful to cremate the remains of more than one individual within the same cremation chamber at the same time.

2. The consumer may choose cremation without choosing embalming services. However, if the crematory does not have a refrigerated holding facility it cannot accept human remains for anything other than immediate cremation.

3. The consumer is not required to purchase a casket for the purpose of cremation. CARE CREMATION SERVICE (we will provide) requires that the body of the Decedent Authorizing Agent be delivered for cremation in a suitable container which may be either a casket or an alternative (cremation) container for cremation.

Type of casket or alternative container selected:

4. Due to the nature of the cremation process, any personal possessions or valuable materials, such as dental gold or jewelry, that are left with the Decedent Authorizing Agent and not removed from the casket or alternative container prior to cremation will be destroyed or will otherwise not be recoverable.

5.

6. Cremated remains shall not be contaminated (insofar as possible) with foreign material. All non-combustible materials will be separated and removed by visible or magnetic selection and will be disposed of by

, CARE CREMATION SERVICE with similar materials from other cremations in a non-recoverable manner.

7. The original copy of this form shall be retained by the firm or person with which the arrangements are being made. A copy shall be provided to the Decedent Authorizing Agent.

A person arranging his/her own cremation shall have the right to transfer or cancel this authorization at any time prior to death by notifying in person, or by certified mail, the firm or person with which the pre-need authorization form is filed.

8. In the event that no different or inconsistent instructions are provided to

at the time of death, CARE CREMATION SERVICE shall release or dispose of the cremated remains as indicated on this pre-need authorization.

9. In the event there is a conflict between the Decedent Authorizing Agent's pre-need authorization and the demands of the next class of authorizing agent,

, CARE CREMATION SERVICE shall not accept for cremation the Decedent Authorizing Agent's remains without an order deciding the issues.

The order may be issued by the court after a petition for resolution has been initiated by any natural person in the next class of authorizing agent or

unless extraordinary circumstances exist, the court shall give due deference to the desire of the Decedent Authorizing Agent as expressed in the pre-need cremation authorization (CR-3).

FINAL DISPOSITION

Disposition shall be by: (please mark and complete the chosen disposition)

1) Interment:

2) Scattering in scattering area or garden:

3) Scattering on private property with the permission of the owner:

4) Delivery either in person or by registered mail to:

5) Picked up at the crematory office by:

SIGNATURE OF THE AUTHORIZING AGENT

By executing this cremation authorization form, as Authorizing Agent, the undersigned warrant that all representations and statements contained on this form are true and correct, that these statements were made to induce CARE CREMATION SERVICE to cremate the human remains of the Authorizing Agent, and that the undersigned has read and understands the provisions contained on this form.

Executed at , this day of ,

SIGNATURE OF FUNERAL DIRECTOR OR OTHER INDIVIDUAL AS WITNESS FOR THE SIGNATURE OF AUTHORIZING AGENT