At Need Forms – Simple Cremation

Authorization Form

Deceased Name*

Today’s Date*

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Today’s Time*

: HH

MM

Date of Death*

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DD

YYYY

Your Name*

We, the undersigned, hereby certify that we are the legal custodians or same and nearest degree of relationship of the herein named Deceased, having full legal authority and responsibility for the final disposition of the deceased. We hereby certify and represent that the remains delivered are those of the herein named Deceased and further represent under penalty of perjury that we have the right to control the disposition of said remains.

We, jointly and severally, authorize Simple Cremation and its assigns to care for, prepare, cremate, ship or dispose of the deceased according to the following instructions and approvals:

We hereby agree to indemnify and hold harmless Simple Cremation, including any officers, agents, affiliates, and employees, harmless from any and all loss, cost, or damages, it or they may suffer or incur by reason of acting upon the authorization set forth herein for acting and providing services in accordance with its customary practices along with the rules, regulations, and laws of State of Nevada. Simple Cremation makes no warranties, expressed or implied, and any damages shall be limited to any fees paid. I/We understand that The Company will seek legal action towards the undersigned if there is any form of misrepresentation or fraud on My/Our part while acting as the Authorizing Agent.

NOTE: Care and Storage, including the cremation process of human remains occur at 5450 Stephanie Street, Las Vegas, NV 89122.

Simple Cremation and its agents may rely upon the hereinafter releases and authorizations when providing such services.

1. Release of Deceased to Simple Cremation

We hereby authorize any care provider, hospice, hospital, coroner, or other facility to release the remains of the Deceased Simple Cremation to provide services. We understand that all charges and fees for services shall be paid in full prior to the completion of any other services beyond initial removal of the Deceased.

Signature

Relationship

Signature

Relationship

2. Cremation Authorization (to be completed and acknowledged by the Legal Next-of-Kin)

Consent*

We hereby authorize Simple Cremation to cremate the Deceased and understand the remains will not be accepted for cremation unless they are in a suitable rigid container.

Consent*

We certify that we are not aware of any objection to cremation by any person who has a right to control the disposition of the remains;

Consent*

We acknowledge that we may be held liable under penalty of perjury pursuant NRS 199.145 (Category D Felony as provided in NRS 193.130) for making a willful and false statement of material fact relating to your status as an Authorizing Person under NRS 451.024;

NRS 451.024 designates the following persons, in the following order of priority, who may order the burial or cremation of human remains of a deceased person;

PLEASE CHECK ANY OF THE FOLLOWING WHO EXIST TO YOUR KNOWLEDGE OR BELIEF (OTHER THAN YOURSELF):

A person designated as the person with authority to order the burial or cremation of the human remains of the decedent in a legally valid document or a person over the age of 18 with an executed and notarized affidavit pursuant to NRS 451.024(9);
A person authorized to direct disposition of the human remains of decedent under DD Form 93 or its successor form (Active duty Armed Forces of the U.S., a reserve component, or the National Guard);
The spouse of the decedent;
An adult son or daughter of the decedent;
Either parent of the decedent;
An adult brother or sister of the decedent;
A grandparent of the decedent;
A guardian of the person of the decedent at the time of death

Consent*

We certify that we have identified (or have had the opportunity to identify) the remains that were delivered to the Funeral Home as the remains of the Deceased;

Consent*

The remains of the Deceased contain a pacemaker or other explodable implant. If said deceased remains contained such a device at time of death, Simple Cremation is authorized to remove and dispose of all such devices;

Consent*

The remains of the Deceased do NOT contain a pacemaker or other explodable implant.

Did the death occur from a communicable or otherwise dangerous disease?*

We understand the cremated remains are bone fragments, which will be reduced to permit their placement in an urn or other container. In the event the capacity of the urn or other container is insufficient to accommodate all of the remains, Simple Cremation will put the additional remains in a sealed separate plastic bag unless otherwise instructed in writing by the undersigned. All noncombustible materials delivered with the body will be disposed of at the company's direction. Reasonable efforts will be exercised in keeping cremated remains separate. However, it is impossible to guarantee or warrant that some bone particles or the residue of one cremation would not possibly be mixed with those of another cremation.

Consent*

We understand the cremated remains are bone fragments, which will be reduced to permit their placement in an urn or other container. In the event the capacity of the urn or other container is insufficient to accommodate all of the remains, Simple Cremation will put the additional remains in a sealed separate plastic bag unless otherwise instructed in writing by the undersigned. All noncombustible materials delivered with the body will be disposed of at the company's direction. Reasonable efforts will be exercised in keeping cremated remains separate. However, it is impossible to guarantee or warrant that some bone particles or the residue of one cremation would not possibly be mixed with those of another cremation. Decedent’s Name: Date of Death

I/We authorize Simple Cremation to separate and remove all non-combustible metal materials including but not limited to, hinges, latches, nails, screws, staples, fillings, precious metals, metal prosthesis or implants to which any bone particles or other human residue may be affixed and forwarded to an approved recycling facility. These items shall be disposed of and/or recycled.

Consent*

The crematory is authorized to perform the cremation upon receipt of the human remains, at its discretion, and according to its own time schedule without obtaining further authorizations or instructions.

We hereby authorize Simple Cremation to cremate the Decedent pursuant to NRS 451.024 and NRS 451.655(4) and further acknowledge NRS 451.655(4) and NRS 451.705, which state: NRS 451.655(4) Order of person for cremation and disposition of remains. . . . 4. If a completed order for cremation, executed before death, and the human remains to which it pertains are in the possession of the operator of a crematory, and the operator has received payment for the cremation and the disposition of the cremated remains, the operator shall perform those acts as ordered and incurs no liability by their performance. NRS 451.705 Effect of execution of order for cremation; liability for article of value delivered with remains. 1. The signer of an order for the cremation of human remains warrants the truth of the facts set forth in the order, including the identity of the person whose remains are to be cremated, and his or her own authority to order cremation. The signer is personally liable for any damage resulting from the falsity of a warranted fact or from his or her lack of authority. 2. The operator of a crematory may cremate human remains upon receipt of an order signed by the agent. The operator has no liability for cremating the remains or releasing the cremated remains pursuant to the order. 3. The operator of a crematory is not liable for any article of value delivered with human remains.

Signature*

Address*

Street Address City State ZIP Code

Relationship*

Signature

Address

Street Address City State ZIP Code

Relationship

Release remains to*

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All charges and fees for services shall be paid in full prior to the completion of any other services beyond initial removal of the Deceased.

Step 1 of 5

VITAL STATS INFORMATION

(All information below pertains to the deceased.)

CREMATION TIMELINE STATEMENT AND ACKNOWLEDGEMENT

CREMATION TIMELINE STATEMENT AND ACKNOWLEDGEMENT

Authorization Form