Authorization to Cremate Form Cremation Authorization Form Name of the Deceased(Required)Date of Birth(Required) MM slash DD slash YYYY Date of Death(Required) MM slash DD slash YYYY Gender(Required) Male Female Age(Required)Place of Death: City, Borough, Twp.(Required) Street Address City 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 Decedent’s Last Principal Residence(Required) Street Address City 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 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(Required)DISPOSITION OF REMAINS(Required) Return to funeral director Deliver to (please specify below) 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(Required)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/herRelationship(Required)or that I otherwise serve (served) in capacity ofRoleName(Required)Email(Required) Witness at Signing(Required)
