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Cremation Authorization Form

 

Authorization for Cremation and Disposition

Notice: THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.  CREMATION IS IRREVERSIBLE AND FINAL.  READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.

I/We, the undersigned, certify, warrant and represent that I/We have the full legal right and authority to authorize the cremation, processing and disposition of the remains of:

_____________________________________________________________________
(hereinafter referred to as the “Deceased”).

I/We hereby request and authorize Dvorak Funeral Home (hereinafter referred to as the “Funeral Home”) to take possession of and make arrangements for the cremation of the remains of the Deceased at:

 _____________________________________________________________________
(hereinafter referred to as the “Crematory”).

I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custody of the Funeral Home.  I/We understand that the services and obligations of the crematory shall be fulfilled when the cremated remains of the Deceased are returned to the possession of the Funeral Home.  I/We hereby authorize the Funeral Home to arrange for disposition of the cremated remains of the Deceased as follows:

 ________________________________________________________________________________
(Description of Cremation Container)

________________________________________________________________________________
(Description of Additional Cremation Containers and Keepsakes)

Deliver/Release/Ship To: (Circle Choice):

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

The cremation, processing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all governing laws, the rules, regulations and policies of the Crematory and Funeral Home, and the following terms and conditions:

1.        The remains of the Deceased will not be accepted for cremation unless received by the Crematory in a combustible, leak resistant, rigid cremation container. The Crematory is authorized to remove and dispose of handles, ornaments and any other non-combustible items attached to the cremation container prior to cremation.

2.        I/We hereby authorize the Funeral Home, its agents and employees, to remove any such mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) prior to cremation, and dispose of such items at its discretion.

3.        I/We agree to indemnify, release and hold the Crematory, the Funeral Home, their affiliates, agents, employees and assigns, harmless from any and all loss, damages, liability or causes of action (including attorney’s fees and expenses of litigation) in connection with the cremation and disposition of the cremated remains of the Deceased, as authorized herein, or my/our failure to correctly identify the remains of the Deceased, disclose the presence of any implanted mechanical or radioactive devices, or take possession of, or make permanent arrangements for the disposition of such remains.

Signature of Person(s) Authorizing Cremation and Disposition:
X_______________________________________________ Date _________________________
Print Name: ___________________________________Relationship: _____________________
Address: ______________________________________________________________________
Phone: ________________________________________

Additional Signature of Person(s) Authorizing Cremation and Disposition:
X_______________________________________________ Date _________________________
Print Name: ___________________________________Relationship: _____________________
Address: ______________________________________________________________________
Phone: ________________________________________


Dvorak Funeral Home Representative: __________________________________________________
Date: ________________________________________

Directions:

Complete and sign the form.  Fax, mail, email, or deliver the signed authorization to:

Dvorak Funeral Home and Professional Services
4307 Cochins LN
Pasco, WA. 99301

509-412-1147 Office
509-412-1147 Fax
DvorakFuneralHome.com
Email