cREMATION fORM

This Authorization Form must be completed and signed prior to the cremation. Please read it carefully and ask us any questions you may have. Cremation is an irreversible and final process. It is important that you understand the cremation process that is described in Section 8 of this Authorization Form prior to signing. We want you to fully understand the information provided in this Authorization Form, so we will be happy to answer any questions about the cremation process or any other information in this form. THIS AUTHORIZATION FORM IS NOT A CONTRACT FOR CREMATION SERVICES. A SEPERATE CONTRACT OR CONTRACTS WILL BE REQUIRED TO PURCHASE THE SERVICES OF THE FUNERAL HOME AND/OR CREMATORY.

BECAUSE CREMATION IS IRREVERSIBLE, IDENTIFICATION OF THE DECEDENT IS REQUIRED BY ONE OF THE FOLLOWING METHODS:

2. Funeral Home & Crematory

The Authorizing Agent authorizes the Funeral Home & Crematory set forth below to carry out the directions and instructions of the Authorizing Agent contained in the form.

3. Authorizing Agent

(a) The Health Care Agent or someone appointed by the Decedent in an Affidavit or DD Form 93 to have the right of disposition.

(b) The Decedent's surviving spouse.

(c) The Decedent's surviving child or children.

(d) The Decedent's surviving parent or parents.

(e) The Decedent's surviving sibling or siblings.

(f) The Decedent's surviving grandparent or grandparents.

(g) The Decedent's personal guardian at the time of death.

(h) The personal representative of the estate of the Decedent.

(i) The persons in the classes of the next degree kinship, in descending order, under the laws of decent and distribution to inherit the estate of the decedent.

(j) The final disposition of the Decedent's remains is the responsibility of the state or a political subdivision of the state, the public office or employee responsible for arranging the final disposition of the remains.

(k) Any person willing to assume the right of disposition, including the personal representative of the estate or the licensed funeral director with the custody of the body, after attesting in writing and good faith that they could not locate any of the persons in the above priority list.

4. Authority of Authorizing Agent

As Authorizing Agent, I have reviewed the priority list in #3 and I represent that I have the right to authorize the cremation of the decedent's remains and I am initialing one of the following statements below accordingly:

5. Pacemakers, Implants, and Protheses

Pacemakers, defibrilators, radioactive implants, silicon or other implants, mechanical devices or prostheses may create a hazardous condition when placed in the cremation chamber and subject to heat. As authorizing Agent, I have listed all devices (including mechanical, prosthetic, implants, or materials), which may have been implanted in or attached to the decedent.

6. Casket or Alternative Container

The remains are to be cremated in a combustible casket or alternative container that is capable of being completely closed, is resistant to leakage or spillage, is sufficiantly rigid to be handled easily, and provides protection for the health and safety of Crematory and Funeral Home personnel. The Crematory is authorized to inspect the casket or alternative container, including opening it if necessary. In the event that the casket or container does not meet the above requirements, the Crematory will nofify the Authorizing Agent. Many caskets that are comprised primarily of comustible material also contain some exterior parts (decorative handles or rails) that are not combustible and that may cause damage to the cremation equipment. As Authorizing Agent, I authorize Crematory, in its discretion , to remove and discard the non-combustive materials. I understand that some crematories will not accept metal or fiberglass caskets. I further understand that the casket or alternitive container will be consumed as part of the cremation process.

7. Witnesses

Witnessing a cremation can be an emotional experience. Witnesses are assuming the risks involved and fully release the Funeral Home and Crematory from any liability, to the extent permitted by Crematory. The persons listed are authorized to be present at the cremation room prior to and during the cremation of the Decedent's remains and during the removal of the cremated remains from the cremation chamber. If you desire witnesses, initial accordingly and list their names.

8. The Cremation Process

The cremation of the Decedent's remains may take place before or after ceremonies to memorialize the Decedent. Cremation is performed to prepare the remains of the Decedent for final disposition. It is carried out by placing the Decedent's remains in the casket or alternative container, which is then placed into a cremation chamber or retort where they are subjected to intense heat and flame. All cremations performed individually. During the cremation process it may be necessary to open the cremation chamber and reposition the remains of the Decedent in order to facilitate a complete and thorough cremation. Through the use of a suitable fuel, the incineration of the container and its contents is accomplished and all substances are consumed or driven off, except bone fragments (calcium compounds) and metal (including dental gold and silver and other non-human materials) as the temperature is not sufficient to consume them.

Due to the nature of the cremation process, any personal possessions or valuable materials, such as dental gold or jewelry (as well as any prostheses or dental bridgework) that are left with the remains and not removed from the casket or container prior to the cremation may be destroyed or if not destroyed, will be disposed of by the crematory. The Authorizing Agent understands that arrangements must be made with the Funeral Home to remove any such posessions or valuables prior to the time that the remains of the Decedent are transported to the Crematory.

9. Authorization to Cremate, Process & Pulverize:

10. Urn or Temporary Container:

11. Final Disposition (Initial option after reading #11):

Following the Cremation, the Authorizing Agent directs the Crematory and/or Funeral Home to undertake the actions set forth to arrange the final disposition of the cremated remains of the Decedent. If the cremated remains are shipped at any time, the Authorizing Agent directs that that Crematory or Funeral Home utilize the U.S. Postal Service's Priority Mail Express Service with a return receipt or a shipping service that uses an internal system of tracking the location of the cremated remains during shipment and requires a signed receipt of the person taking delivery of the cremated remains. If shipment by the U.S. Post Office or other delivery company is directed, the Authorizing Agent acknowledges and agrees that there is a risk that the cremated remains could be lost.

The Authorizing Agent understands that if no arrangement for the final disposition, release or shipment of the cremated remains is made in this Authorization, the Crematory or Funeral Home shall hold the cremated remains for sixty (60) days after cremation. If during that sixty (60) day period, the cremated remains are not retrieved by the person designated in this document to recieve them or by the Authorizing Agent, or if arrangements for their final disposition are not made, notice will be sent to the Authorizing Agent informing the Authorizing Agent that the cremated remains will be interned or stored if not retrieved in the next thirty (30) days.

Thirty (30) days after the written notice is sent to the Authorizing Agent, if no arrangements for the final disposition of the cremated remains have been made or the Authorizing Agent has not taken delivery of or caused the delivery of the cremated remains, then the Funeral Home may dispose of the cremated remains in a grave or crypt, or by storing the cremated remains in the Funeral Home. The Authorizing Agent shall be liable for the cost of such final disposition in a grave or crypt and shall reimburse the Funeral Home immediately upon receipt of an invoice.

12. Personal Property:

All personal property and effects delivered with the remains of the Decedent to the Funeral Home/Crematory, including jewelry, clothes, hair pieces, dental bridgework, eyeglasses, shoes, etc., will be destroyed in the cremation process or otherwise discarded by the crematory, in its sole discretion, unless specific instructions are given by the Authorizing Agent below:

13. Viewing, Visitation & Funeral Ceremonies:

Prior to the cremation of the Decedent's remains, the Authorizing Agent or Decedent's family have arranged for a viewing/ceremony set forth below:

14. Time of Cremation

15. Certification & Indemnification

The Authorizing Agent acknowledges that the Funeral Home and Crematory are relying upon the representations being made by the Authorizing Agent in this Authorization. The Authorizing Agent certifies that all of the information and statements contained in the Authorization are accurate and no omissions of any material fact have been made. The Authorizing Agent agrees to indemnify