Authorization To Cremate Authorization To Cremate FacebookThis field is for validation purposes and should be left unchanged.The undersigned (the “Authorizing Agent(s) or “A.A.”) hereby authorize(s) PEACEWELL CREMATIONS, in accordance with any applicable state or local laws or regulations, to cremate the human remains of:Name of the Deceased(Required)Date of Birth MM slash DD slash YYYY Date of Death MM slash DD slash YYYY Gender Male Female AgePlace of Death: City, Borough, Twp. County AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Decedent’s Last Principal ResidenceThe Authorized Funeral Director isI/WE hereby certify and agree to the following: 1. I/WE HAVE identified the human remains that were delivered to the funeral home as the decedent or accepted the identification used byName of nursing home or hospital(The authority to identify-name of nursing home or hospital) and have authorized the funeral home to deliver the decedent to Peacewell Cremations for cremation. 2. The undersigned is/are over age eighteen and the next of kin and/or have authority to sign and give permission for this cremation. 3. All implanted heart pacemakers, radiation producing devices, or other implanted medical devices that could be explosive or harmful during the cremation process, have or will be removed before delivery for cremation. 4. The undersigned agree(s) to defend, indemnify and hold harmless the crematory company and its representatives from any and all liability whatsoever in performing these services and agrees to be liable for any damages to the crematorium or injury to its personnel if any implanted medical device explodes or causes damage. 5. It is understood that due to the cremation process, any valuable material, including dental gold, will either be destroyed or be beyond recovery. Any personal possession accordingly has been removed or may be destroyed. 6. Peacewell Cremations is authorized to perform the cremation upon receipt of the human remains, at its discretion, and according to its own time schedule, as work permits, without obtaining any further authorization or instructions.DISPOSITION OF REMAINS(Required) Return to funeral director via Registered Mail. (additional fees apply for delivery or registered mail). Inter non-recoverable grave. Hold cremated remains for further instructions to be given within thirty (30) days. (IF NO INSTRUCTIONS ARE RECEIVED WITHIN THIRTY DAYS, Peacewell Cremations is authorized to consign the remains to earth without further notice. It is understood that after consignment, the cremated remains cannot be recovered). Deliver to Deliver ToI/WE assume all liability that may arise from the shipment and hold Peacewell Cremations harmless from any and all claims that may arise therefrom.LIMITATION OF LIABILITY As the Authorizing Agent(s), I (We) hereby agree to hold harmless the "Ivy Hill Cemetery Company", its officers, agents, and employees, of and from any and all claims, demands, causes or causes of action, and suits of every kind, nature and description, in law or equity, including any legal fees, costs and expenses of litigation, arising as a result of, based upon or connected with this authorization, including the failure to properly identify the decedent or the human remains transported to Peacewell Cremations, the processing, shipping and final disposition of the cremated remains, any damage due to harmful or explodable implants, claims brought by any other person(s) claiming the right to control the disposition of the decedent or the decedent’s cremated remains, or any other action performed by Peacewell Cremations, its officers, agents or employees, pursuant to this authorization. The obligation of Peacewell Cremations shall be limited to the cremation of the decedent and the disposition of the decedent’s cremated remains as authorized on this form. No warranties, expressed or implied, are made and total damages are limited whereby in no event shall the total damages amount exceed the amount of the cremation fee paid.SIGNATURE OF AUTHORIZING AGENT(S)I/WE, the undersigned, hereby certify that I am the closest living next of kin of the decedent and that I am related to the decedent as his/herRelationshipor that I otherwise serve (served) in capacity ofRoleto the decedent, that I have charge of the remains of the decedent and as such posses full legal authority and power, to execute this authorization form and to arrange for the cremation and disposition of the cremated remains of the decedent. In addition, I am aware of no objection to this cremation by any interested party, including spouse, child, parent, or sibling.Name(Required)Signature(Required)Email(Required) Witness at SigningNameSignatureDate(Required) MM slash DD slash YYYY REPRESENTATIONS OF FUNERAL DIRECTORName of Funeral HomeAddress City, Borough, Twp. County AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State By executing this authorization form as a licensed funeral director and agent/employee of the Funeral Home indicated above, I warrant to the best of my knowledge the following: That our Funeral Home was responsible for making arrangements with the Authorizing Agent(s) for the cremation of the Decedent and that I have reviewed this authorization form with the Authorizing Agent(s). That no member of our Funeral Home has any knowledge or information that would lead us to believe that any of the answers provided on this form, by the Authorizing Agent(s), are incorrect.SIGNATURE OF FUNERAL DIRECTORNameSignatureDate MM slash DD slash YYYY CAPTCHA
