602 Birch Street Scranton, PA 18505(570) 343-0413CremationsbyCorey.com Cremation Authorization Form 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 Cremation Care by Corey Strauch to Cremations by Corey, LLC 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: Name of decedent:* 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 Heart pacemaker Describe device: 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) I/we the undersigned hereby order the disposition of the cremated remains as follows: Mail to:* Burial in Cemetery: 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. DISCLOSURE (The Cremation Process) The human body burns with the casket, container, or other material in the cremation chamber. Some bone fragments are not combustible at the incineration temperature and, as a result, remain in the cremation chamber. During the cremation, the contents of the chamber may be moved to facilitate incineration. The chamber is composed of ceramic or other material which disintegrates slightly during each cremation and the product of that disintegration is co-mingled with the cremated remains. Nearly all the contents of the cremation chamber, consisting of the cremated remains, disintegrated chamber material and small amounts of residue from previous cremations are removed together and crushed, pulverized or ground to facilitate inurnment or scattering. Some residue remains in the cracks and uneven places of the chamber. Periodically, the accumulation of this residue is removed and interred in a dedicated cemetery property or scattered at sea. I/we have read the foregoing disclosure: Signature of person authorizing cremation and disposition.Date:* DD slash MM slash YYYY 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. Name : Phone # :Email : Name : Phone # :Email : Name : Phone # :Email : I hereby confirm my intention to an Identification viewing of the deceased. We will contact you to schedule the Identification viewing. Identification viewings will take place at our Crematory Location.* I do* I do not wish to view the deceased prior to the cremation. *(Additional charges may apply)Signature of Authorized Agent(Please type your name twice to qualify as digital signature)Signature* Reset signature Signature locked. Reset to sign again Your Relationship to deceased* Your Address* Street Address City State / Province / Region ZIP / Postal Code Your State Driver ID #* Your Date of Birth* MM slash DD slash YYYY Δ
