Cremation Auth

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NOTICE: This is a legal document. It contains important provisions concerning cremation. Cremation is irreversible and final. Read this document carefully before signing.
CREMATION AUTHORIZATION & ORDER FOR DISPOSITION
Pennsylvania Cremation Services, LLC and Strauch Family Crematory now known as (Provider/s)
The undersigned hereby certify and represent that they are the legal custodian (s), having full legal authority to authorize the cremation, processing and disposition of the named decedent, and hereby request and authorize, Providers to make removal, take possession of, make arrangements for and to cause the cremation, processing and disposition of the remains of:
Deceased Person's Name:*
in accordance with and subject to the terms and conditions set forth in this Authorization, the Provider's rules and regulations and any applicable state or local laws, rules or regulations. I/we agree jointly and severally to hold the Provider, its officers, agents, employees and the below named funeral director, harmless from any and all loss, costs, or damages it or they may suffer or incur by reason of acting upon this authorization and order. I/we the undersigned understand and acknowledge that due to the nature of the cremation process, the entire amount of fragment remaining MAY not be included in the urn or container selected and that valuable material, including dental gold will either be destroyed or not be recoverable. (See disclosure) I also authorize the provider to collect a finger print of the decedent for future identification.
I/We the undersigned further State: (Must choose one)*
- The deceased has NO implanted device or prosthesis
- The deceased has an implanted device or prosthesis and I/we authorize and order removal and disposition of same prior to cremation, if necessary
Is the implanted device a Heart Pacemaker?*
- Yes
If "OTHER" please Describe device in the space above. NOTE: Implanted mechanical devices may create a hazardous condition when placed in a cremation chamber. I/we the undersigned agree that in the event of failure to notify the funeral director or Provider or others responsible for the removal of such a device, that the undersigned will be liable for any damages to the crematorium and/or injury to crematorium personnel.
Disposition of Cremated remains (Must choose one)
Mail to:
Family to pick up from the providers main location with in 30 days of cremation
In the event that I have not called for the cremated remains as agree, or directed the final disposition within 30 days of cremation, disposition can be made at the discretion of the Provider/s. I release any liability for this performance and I assume responsibility for the cost of the final disposition.
Signature of person authorizing cremation and disposition.
Please check one:
- I certify that I do not have actual knowledge of any living person who has a superior or equal right to act as the Authorizing Agent.
- There is another living person(s) listed below who has a superior or equal right to act as Authorizing Agent. Please provide the information regarding the other authorized agents below. Cremation can not take place until all legal next of kin of the same level sign a cremation authorization form. The providers will attempt to contact them using the information below.
All other Authorizing Agents of the Deceased
Please list Full Legal Name, Phone Number, Email Address and Mailing Address of any another living person(s) who has a superior or equal right to act as Authorizing Agent. The providers will attempt to contact them using this information.
I want to have an Identification viewing of the deceased. We will contact you to schedule the Identification viewing. ****$400 additional with Economy Cremation Package.**** Included in Simple Cremation Package. Immediate family only. Max 10 people, 30 mins, M-F 10am-3pm
- I do
- I do not
wish to view the deceased prior to the cremation.
Signature of Authorized Agent
(Please type your name twice to qualify as digital signature)
Relationship to deceased*
Digital Signature*
Digital Signature ( repeated)*
Date:*
Address*
Street Address City State ZIP Code
Your State Issued Drivers Lic./ID Number*
Your Date of Birth*
Signature*
Your Name
Your Name
Your Name
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