Cremation Authorization

    

Cremation Authorization Form

Decedent Identification

Last Name:____________________________ First Name:________________________________

Middle Name:__________________________ Suffix:________________________________

Sex:______________ DOB:______________ Birthplace:________________________________

Date of Death:________________________ Time of Death:_____________________________

Place of Death:______________________________ SSN:________________________________

* Remains positively identified by Authorized Representative Initials:___________

Contact Information

Name:_________________________________ Relationship:_____________________________

Phone No.:____________________________ Email:____________________________________

Address:__________________________________________________________________________

Artificial Implants

Mechanical Devices:______________________________ Location(s):____________________

Artificial Implants:_____________________________ Location(s):____________________

Pacemaker:_______________________________________________ Fee:____________________

Authorized Personnel

Funeral Home is authorized by the Decedent's representative to carry out all

instructions and processes

Funeral Home:____________________________________ Contact:________________________

Phone No.:_______________________________________ Email:__________________________

Address:__________________________________________________________________________

Crematorium:_____________________________________ Contact:________________________

Phone No.:_______________________________________ Email:__________________________

Address:__________________________________________________________________________

Service

Date/Time:______________________ Location:_______________________________________

Witness(es):______________________________________________________________________

Representative Signature:___________________________________ Date:________________

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