CREMATION AND DISPOSITION AUTHORIZATION


Today’s Date: 
CREMATION AND DISPOSITION AUTHORIZATION
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 and the Attachment prior to signing it. We want you to fully understand the information provided in this Authorization Form and Attachment, so we will be pleased to answer any questions about the cremation process or the other information in this Form.
THE AUTHORIZATION IS NOT A CONTRACT FOR CREMATION SERVICES. A SEPARATE CONTRACT OR CONTRACTS WILL BE REQUIRED TO PRUCHASE THE SERVICES OF THE FUNERAL HOME AND/OR CREMATORY.
(Print all information except signatures.)

1. IDENTIFICATION OF THE DECEDENT:

  

 

 

 

 

 

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

IDENTIFICATION MADE BY

 Initia Here:  

2. FUNERAL HOME AND CREMATORY

Authorizing Agent authorizes the Funeral Home and Crematory set forth fellow to carry out the directions and instructions of the Authorizing Agent contained in this Authorization.
Leavitt’s Mortuary
Aultorest Memorial Park Crematory
836 36th Street,
Ogden, Utah 84403

3. IDENTIFICATION OF AUTHORIZING AGENT

  

 

 

  

4. AUTHORITY OF AUTHORIZING AGENT

As Authorizing Agent, I represent that I have the right to authorize the cremation of the Decedent’s remains and I am initialing on of the following three statements accordingly:

 

5. PACEMAKERS, IMPLANTS, AND PROSTHESES

Pacemakers, radioactive, silicon or other implants, mechanical devices or prostheses may create a hazardous condition when placed in the cremation chamber and subjected to heat. As Authorizing Agent, I have listed in #5 on the Authorization all devices (including mechanical, prosthetic, implants, or materials), which may have been implanted in or attached to the Decedent.

Description of Devices:   

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As Authorizing Agent, I instruct the Funeral Home to remove each Device listed above and to charge for its services in making or arranging
for such removal. Unless indicated directly below, the Funeral Home is to dispose of all such Devices. The Devices listed are to be removed and returned to the Authorizing Agent: Leavitt’s Crematory

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 sufficiently 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 notify the Authorizing Agent. Many caskets that are comprised of combustible material also may contain some exterior parts (decorative handles or rails) that are not combustible and that may cause damage to the cremation equipment. As Authorizing Agents, I authorize the Crematory, in its discretion, to remove and discard the non-combustible materials. I understand that some crematories will not accept metal or fiberglass caskets. I further understand that the casket or alternative container will be consumed as part of the cremation process.

Casket or Alternative Container  

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 the Crematory, the persons listed on the Authorization 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, you must initial #7 on the Authorization and list their names.

Name of Witness(es)   

 

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 are 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 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 body prostheses or dental bridgework) that are left with the remains and not removed from the casket or container prior to 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 possessions or valuables prior to the time that the remains of the Decedent are transported to the Crematory.
Following a cooling period, the cremated remains, which will normally weigh several pounds in the case of an average-size adult, are then swept or raked from the cremation chamber. Although the Crematory will take reasonable efforts to remove all of the cremated remains from the cremation chamber. Although the Crematory will take reasonable efforts to remove all of the cremated remains from the cremation chamber, it is impossible to remove all of them, as some dust and other residue from the process will be left behind. In addition, while every effort will be made to avoid commingling, inadvertent and incidental commingling of minute particles of cremated remains from the residues of previous cremations is a possibility, and the Authorizing Agent understands and accepts this fact.
After the cremated remains are removed from the cremation chamber, all non-combustible material (insofar as possible) such as dental bridgework and hinges, latches, and nails from the container will be separated and removed from the human bone fragments by visible or magnetic selection. The Crematory is authorized to dispose of these materials with similar materials from other cremations in a non-recoverable manner, so that only human bone fragments will remain.
When the cremated remains are removed from the cremation chamber, the skeletal remains often will contain recognizable bone fragments. Unless otherwise specified, after the bone fragments have been separated from the other material, they will be mechanically pulverized. The process of crushing or grinding may cause incidental commingling of the remains with the residue from the processing of previously cremated remains. These granulated particles of unidentifiable dimensions, which are virtually unrecognizable as human remains, will then be placed into a designated container.

9. AUTHORIZATION TO CREMATE, PROCESS AND PULVERIZE

As Authorizing Agent, I have read and understand the description of the cremation process contained in #8 on the Attachment and authorize the cremation, processing and pulverization of the remains of the Decedent. I further authorize the Funeral Home to deliver the Decedent’s remains to the Crematory for the purpose of cremation.

10. URN OR TEMPORARY CONTAINER 

After the cremated remains have been processed they will be placed in the urn listed on the Authorization or, if an urn is not provided to the Crematory, in a temporary container provided by the Crematory. The Authorizing Agent acknowledges that it is impossible to recover all of the dust and residue from the cremation and processing.
In the case of an adult, it is recommended that the urn or temporary container be a minimum size of 200 cubic inches. In the event the urn or temporary container is insufficient to accommodate all of the cremated remains, the excess will be placed by the Crematory in a secondary container. This secondary container will be kept with the urn or the temporary container and handled according to the final disposition instruction set forth in Section 11 below; provided, however, that the secondary container may not be designed for shipping. All urn or containers provided to the Funeral Home or Crematory must be appropriate for shipping. The Authorizing Agent directs the Crematory to use the specified urn or container listed in on the Authorization.

Standard temporary shipping container provided by Crematory.

11. FINAL DISPOSITION

Following the cremation, the Authorizing Agent directs the Crematory and/or Funeral Home to undertake the actions set forth on the attachment 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 the Crematory or Funeral Home utilize registered U.S. mail with a return receipt or a shipping service that uses an internal system for tracing the location of the cremated remains during shipment and requires a signed receipt of the person taking delivery of the cremated remains.
The Authorizing Agent understands that if no arrangements for the final disposition, release or shipment of the cremated remains are made in the Authorization, the Crematory and/or the Funeral Home shall hold the cremated remains for thirty (30) days after cremation. If during that thirty (30) day period the cremated remains are not retrieved by the person designated above to receive them or by the Authorizing Agent, or if arrangements for their final disposition are not made, then the Crematory or Funeral Home may return the cremated remains to the Authorizing Agent at the address listed in Section #3 of the Authorization. In the alternative, if no arrangements for the final disposition of the cremated remains have been made within sixty (60) day period because of the inaction of a party other than the Crematory or Funeral Home, then the Crematory or Funeral Home may dispose of the cremated remains in a grave, crypt or niche. The Authorizing Agent shall be liable for the cost of such final disposition in a grave, crypt or niche and shall reimburse the Crematory or Funeral Home immediately upon receipt of an invoice.

 

( ) remains of the Decedent for disposition as follows:

Deliver to _________________________________________

cemetery with which arrangements have already been made.

Deliver or release to:

 

12. PERSONAL PROPERTY

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

13. VISITATION AND FUNERAL CEREMONIES

Prior to the cremation of the Decedent’s remains, the Authorizing Agent or the Decedent’s family has arranged for a visitation and/or funeral ceremony as set forth below:

 

 

14. TIME OF CREMATION

 

15. CERTIFICATION AND 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 and hold harmless the Funeral Home and the Crematory, their officers, directors, employees and agents from any and all claims, demands, actions, causes of action or suits of any kind or nature whatsoever, including, but not limited to, any legal fees arising out of or resulting from the Funeral Home’s and the Crematory’s reliance on or performance consistent with the directions, statements, representatives and agreements contained in the Authorization.

Executed on this date

Name of Authorizing Agent(s):

Relationship to family:     

 

 

Leave this empty:

Leavitt's Mortuary & Aultorest Memorial Park http://www.leavittsmortuary.com
Signature Certificate
Document name: CREMATION AND DISPOSITION AUTHORIZATION
Unique Document ID: 5c4e2ff2a35e8fa43a616f11321e47136ba128b2
Timestamp Audit
2017-04-12 13:31:02 MSTCREMATION AND DISPOSITION AUTHORIZATION Uploaded by Mike Leavitts - rmcguire@mkjmarketing.com IP 192.88.135.6