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Legal Next of Kin Name*

First Last

Legal Next of Kin Phone*

Legal Next of Kin Email*

At Need Cremation Package

Price:

Would you like to add Simple Cremation Aftercare?

With aftercare, you receive expert guidance on matters like securing death certificates, navigating life insurance, applying for Social Security, understanding pensions, notifying employers and creditors, etc.)

All information below pertains to the deceased.

Requested information will be used for the death record. If a form field does not apply to you, enter "N/A" or "Unknown" in the field.

Deceased Name*

First Middle Last

Deceased Home Address*

Street Address Address Line 2 City State ZIP Code

County in which the deceased lived*

All information below pertains to the deceased.

Requested information will be used for the death record. If a form field does not apply to you, enter "N/A" or "Unknown" in the field.

Date of Birth*

Month

Day

Year

Age*

State of Birth*

All information below pertains to the deceased.

Requested information will be used for the death record. If a form field does not apply to you, enter "N/A" or "Unknown" in the field.

Gender*

Social Security Number of Decedent*

Citizen of what Country*

Country

All information below pertains to the deceased.

Requested information will be used for the death record. If a form field does not apply to you, enter "N/A" or "Unknown" in the field.

Race

Hispanic Origin

If Other Description

All information below pertains to the deceased.

Requested information will be used for the death record. If a form field does not apply to you, enter "N/A" or "Unknown" in the field.

Years in School*

Number of Years in School

Degree

All information below pertains to the deceased.

Requested information will be used for the death record. If a form field does not apply to you, enter "N/A" or "Unknown" in the field.

Ever in the US Armed Forces*

Branch

All information below pertains to the deceased.

Requested information will be used for the death record. If a form field does not apply to you, enter "N/A" or "Unknown" in the field.

Usual Occupation

Cannot use "Retired" for Occupation field.

Kind of Business or Industry

All information below pertains to the deceased.

Requested information will be used for the death record. If a form field does not apply to you, enter "N/A" or "Unknown" in the field.

Biological/Adoptive Father’s Full Legal Name*

First Middle Last

Biological/Adoptive Mother’s Full Legal Name with Maiden Name*

Please provide maiden name

First Middle Last

All information below pertains to the deceased.

Requested information will be used for the death record. If a form field does not apply to you, enter "N/A" or "Unknown" in the field.

Marital Status*

Surviving Spouse

If female, please provide maiden name

First Middle Last

All information below pertains to the deceased.

Requested information will be used for the death record. If a form field does not apply to you, enter "N/A" or "Unknown" in the field.

Date of Death

Month

Day

Year

Pronounced Time of Death

Hours

Minutes

AM/PM

County of Death*

All information below pertains to the deceased.

Requested information will be used for the death record. If a form field does not apply to you, enter "N/A" or "Unknown" in the field.

Place of Death*

Name of the Facility or Company*

Address of Location of Death

Street Address Address Line 2 City State ZIP Code

If Hospital, Please indicate DOA, OP/Emergency, Inpatient, ICU, Other

All information below pertains to the deceased.

Requested information will be used for the death record. If a form field does not apply to you, enter "N/A" or "Unknown" in the field.

Place of Death

Legal Next of Kin Name*

First Middle Last

Relationship to Deceased*

Legal Next of Kin Address*

Street Address City State ZIP Code

All information below pertains to the deceased.

Requested information will be used for the death record. If a form field does not apply to you, enter "N/A" or "Unknown" in the field.

Is your loved one currently at a funeral home other than Simple Cremation?*

Yes

If yes, which funeral home?

Location*

Is this a Coroner's Case?

CREMATION TIMELINE STATEMENT AND ACKNOWLEDGEMENT

The timeline for a completed cremation is APPROXIMATELY 15 BUSINESS DAYS from the completion of arrangements (all necessary signatures, data needed to produce a Death Certificate, AND payment received). This is NOT a guarantee. This is NOT a guarantee due to circumstances outside of the control of the Company (e.g., a doctor’s signature is required, which may extend the time period). Weekends and holidays ARE NOT INCLUDED IN THE 15-DAY TIME PERIOD.

Once arrangements are completed, the Original Death Certificate is prepared by our staff and sent electronically to the attending physician’s office, hospital, hospice, or other facilities as directed by the doctor that is responsible for signing the Death Certificate. Once the doctor has signed the Death Certificate, it is submitted to the County Coroner’s office, then the Nevada Health District where, if they agree that the cause(s) are acceptable, a permit is generated for cremation.

Once the permit is received, it, along with the Cremation Authorization Forms and accompanying documents, are given to our crematory to be scheduled. We do not place a greater importance on one decedent over another. Cremations are done chronologically.

If, for whatever reason, you want the cremation to take place within a shorter timeframe, you can pay a “rush charge".

* For cremation WITHIN 1 BUSINESS DAY OF RECEIPT OF PERMIT: $350

Cremation time varies with each individual decedent, but the process usually takes between 2 to 4 hours to complete. We only cremate ONE BODY AT A TIME. Once the cremated remains are ready, we will contact the legal next-of-kin.

If cremated remains are not picked up or suitable arrangements for the remains have not been arranged for (i.e. - scattering, mailing, etc.), there will be a storage fee of $35 PER MONTH after 30 days from the date of cremation.

All care, storage and the cremation process of human remains occurs at 5301 Longley Lane, Suite E-180, Reno, NV 89511. Cremations may also be performed at 437 Stoker Ave., Reno, Nevada 89503.

The following disclosure is required pursuant to NAC 642.156:
The Direct Cremation Facility is unable to:
(a) Provide any rites or ceremonies in connection with the final disposition of the human remains of the deceased person;
(b) Provide facilities to conduct rites or ceremonies in connection with the final disposition of the human remains of the deceased person;
(c) Embalm the human remains of the deceased person;
(d) Provide a burial service for the human remains of the deceased person; or
(e) Provide for a viewing, other than an identification viewing, of the human remains of the deceased person.

“BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE PREVIOUS STATEMENTS.

Request Rush Service?

Legal Next of Kin Signature*

Legal Next of Kin Name*

First Middle Last

CREMATION TIMELINE STATEMENT AND ACKNOWLEDGEMENT

The timeline for a completed cremation is APPROXIMATELY 15 BUSINESS DAYS from the completion of arrangements (all necessary signatures, data needed to produce a Death Certificate, AND payment received). This is NOT a guarantee. This is NOT a guarantee due to circumstances outside of the control of the Company (e.g., a doctor’s signature is required, which may extend the time period). Weekends and holidays ARE NOT INCLUDED IN THE 15-DAY TIME PERIOD.

Once arrangements are completed, the Original Death Certificate is prepared by our staff and sent electronically to the attending physician’s office, hospital, hospice, or other facilities as directed by the doctor that is responsible for signing the Death Certificate. Once the doctor has signed the Death Certificate, it is submitted to the County Coroner’s office, then the Nevada Health District where, if they agree that the cause(s) are acceptable, a permit is generated for cremation.

Once the permit is received, it, along with the Cremation Authorization Forms and accompanying documents, are given to our crematory to be scheduled. We do not place a greater importance on one decedent over another. Cremations are done chronologically.

If, for whatever reason, you want the cremation to take place within a shorter timeframe, you can pay a “rush charge".

* For cremation WITHIN 1 BUSINESS DAY OF RECEIPT OF PERMIT: $350

Cremation time varies with each individual decedent, but the process usually takes between 2 to 4 hours to complete. We only cremate ONE BODY AT A TIME. Once the cremated remains are ready, we will contact the legal next-of-kin.

If cremated remains are not picked up or suitable arrangements for the remains have not been arranged for (i.e. - scattering, mailing, etc.), there will be a storage fee of $35 PER MONTH after 30 days from the date of cremation.

All care, storage and the cremation process of human remains occurs at 5450 Stephanie St. Las Vegas, NV 89122.

The following disclosure is required pursuant to NAC 642.156:
The Direct Cremation Facility is unable to:
(a) Provide any rites or ceremonies in connection with the final disposition of the human remains of the deceased person;
(b) Provide facilities to conduct rites or ceremonies in connection with the final disposition of the human remains of the deceased person;
(c) Embalm the human remains of the deceased person;
(d) Provide a burial service for the human remains of the deceased person; or
(e) Provide for a viewing, other than an identification viewing, of the human remains of the deceased person.

“BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE PREVIOUS STATEMENTS.

Signature*

Your Name/Signatory*

First Middle Last

Death Certificates

Southern Nevada Death Certificates: $38 for the first one $25 for each additional one Plus a one-time $40 ordering fee Northern Nevada and Washoe County Death certificates are $25 each with a $40 ordering fee.

Death Certificates*

Order one Southern Nevada Death Certificate

Order one Northern Nevada Death Certificate

No Death Certificates

Additional Death Certificates Quantity

Price: $25.00

Quantity

Additional Death Certificates Quantity

Price: $25.00

Quantity

Choose your delivery method*

Certificates must be shipped to the informant who is listed on the death certificate.

If you prefer to choose an option not shown, the cost of option E will be applied towards the purchase on the alternative urn.

Choose an Urn*

Make a selection to see an image of the urn.

A - Rosewood Urn Tree of Life (wood) $139.00 + tax

B - Green Tree of Life Urn (Brass) $359.00 + tax

C - Pewter Gloss Urn $179.00 + tax

D - Serenity Scattering Box $199 + tax

E - Acacia Urn (wood) $99.00 + tax

For additional options and personalization please call: Southern Nevada: 702-273-3844 Northern Nevada: 775-324-3720

Deceased Name*

First Middle Last

Legal Next of Kin Name*

First Middle Last

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.

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 5301 Longley Lane #E-180 Reno, NV 89511.

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.

Legal Next of Kin Signature*

Relationship to Deceased*

Cremation Authorization

To be completed and acknowledged by the Legal Next-of-Kin. THE PURPOSE OF THIS FORM IS TO ORDER DECEDENT’S CREMATION AND DISPOSITION BY A PERSON WITH LEGAL AUTHORITY.

Name of Decedent*

First Last

Date of Death:

Month

Day

Year

Consent*

The Authorizing Agent authorizes the following Direct Cremation Facility and Crematory to carry out the directions and instructions contained in this authorization. Care and storage, including the cremation process of human remains occurs at the Crematory address noted below:

DIRECT CREMATION FACILITY: SIMPLE CREMATION, INC

CREMATORY: LA PALOMA FUNERAL SERVICES, LLC

ADDRESS: 5301 Longley Ln Ste E-180, Reno, NV 89511

Consent*

DIRECT CREMATION FACILITY: SIMPLE CREMATION, INC

CREMATORY: LA PALOMA FUNERAL SERVICES, LLC

ADDRESS: 5450 Stephanie St, Las Vegas, NV 89122

Consent*

I HEREBY CERTIFY THAT I HAVE LEGAL AUTHORITY AND RESPONSIBILITY TO ORDER THE CREMATION, FINAL DISPOSITION AND RECEIPT OF THE AFOREMENTIONED DECEDENT’S REMAINS AND THAT I AM AWARE OF NO OBJECTION TO CREMATION BY ANY PERSON WHO HAS A RIGHT TO CONTROL THE DISPOSITION OF SAME. I AUTHORIZE THE DIRECT CREMATION FACILITY AND CREMATORY TO CARE FOR, PREPARE, CREMATE, SHIP, OR DISPOSE OF THE DECEDENT ACCORDING TO THEIR DISCRETION AND ACCORDING TO THEIR OWN TIME SCHEDULE WITHOUT OBTAINING FURTHER/ADDITIONAL AUTHORIZATIONS OR INSTRUCTIONS.

Signature of Authorizing Agent*

Date*

Month

Day

Year

Name of Authorizing Agent*

First Last

Relationship*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Select one

AS AUTHORIZING AGENT, I CERTIFY AND REPRESENT THE FOLLOWING*

I DO NOT have actual knowledge of any living person who has a superior right to act as Authorizing Agent.

There is another living person(s) listed below who has a superior or equal right to act as Authorizing Agent. That person has provided me written permission to serve as Authorizing Agent. (e.g., Transfer of Authority)

There is another living person(s) listed below who has a superior or equal right to act as Authorizing Agent. I have made all reasonable efforts to contact such person(s), but have been unable to do so. I have no reason to believe that such person(s) would object to the cremation of Decedent’s remains or my/our authority to act as Authorizing Agent(s).

There is another living person(s) listed below who has a superior or equal right to act as Authorizing Agent. Such person(s) is unable or unwilling to act as Authorizing Agent and thereby refuses to arrange for Decedent’s disposition.

If the Authorizing Agent identified in Section 3 above does NOT have authority through a Legally Valid Document, US Dept. of Defense Record of Emergency Data (DD Form 93), and/or by relationship to the Decedent as a spouse, child, parent, sibling, grandparent, or guardian, please certify with your initials and complete the following affidavit pursuant to NRS 451.024(2):*

I hereby certify that I am at least 18 years of age, have a personal relationship with the deceased and have known him/her for (duration of relationship). I do not know the whereabouts of any other persons who may have priority to authorize cremation and I willingly accept legal and financial responsibility for the burial and cremation of the human remains of the decedent.

Duration of relationship*

Decedent’s remains contain a pacemaker or other explodable implant.. If applicable, I/we authorize the Direct Cremation Facility/Crematory to remove and dispose of all such devices at their discretion.*

Yes, 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.

No, the remains of the Deceased do NOT contain a pacemaker or other explodable implant.

If yes, $75 charge for removal fee.

Price:

If Yes, describe the Device

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

If yes, describe the condition

Consent*

I acknowledge that the cremated remains are bone fragments, which will be placed in an urn/container. In the event the capacity of the urn/container is insufficient to accommodate all of the remains, La Paloma Funeral Services will put the additional remains in a sealed separate plastic bag unless otherwise instructed in writing by the undersigned. Reasonable efforts will be exercised in keeping cremated remains separate. However, it is impossible to guarantee or warrant that some bone particles, dust or the residue of one cremation would not possibly be mixed with those of another cremation.

Consent*

All personal property and effects delivered with the remains of the Decedent to the Direct Cremation Facility/Crematory, including jewelry, clothes, hair pieces, dental bridgework, eyeglasses, and shoes, will be destroyed in the cremation process or otherwise disposed of by the Crematory in its sole discretion.

Consent*

I authorize the Direct Cremation Facility and Crematory to separate and remove all non-combustible metal materials after cremation including, but not limited to, hinges, lathes, nails, screws, staples, fillings, precious metals, dental fillings, 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 at the Direct Cremation Facility’s/Crematory’s sole discretion.

Consent*

I authorize the Direct Cremation Facility and Crematory to dispose of the cremated remains in any manner not prohibited by law if I fail to claim and retrieve the cremated remains within 2 years after cremation. This authorization extends, but is not limited to, scattering upon private property set aside for this purpose as permitted by NRS 451.700(3).

Consent*

I understand the remains will not be accepted for cremation unless they are in a suitable rigid container.

I further acknowledge NRS 451.705, which states in part:

Consent*

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;

Consent*

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; and

Consent*

The operator of a crematory is not liable for any article of value delivered with human remains.

RELEASE OF CREMATED REMAINS

The Authorizing Agent does hereby give the following instructions for the disposition of decedent’s cremated remains by:

Do you want your remains shipped?*

Ship decedent’s cremated remains via USPS Express Mail.
(Additional $150)

Release decedent’s cremated remains for pick up.

Releasing decedent’s cremated remains for pick up to:

First Last

Phone

Releasing decedent’s cremated remains for pick up to:

First Last

Phone

Additional Authorized Person(s) to pick up

Shipping decedent’s cremated remains via USPS Express Mail to:

Name

Phone

Address for shipping

Street Address City State ZIP Code

The Authorizing Agent(s) acknowledge(s) that the Direct Cremation Facility/Crematory are relying upon the representations herein and certifies that the information and statements contained in the authorization are true and accurate and no omissions of any material fact have been made.*

I further hereby agree to indemnify and hold harmless the Direct Cremation Facility and Crematory, including its officers, agents, affiliates, employees, and assigns from any and all loss, cost, or damages, it or they may suffer or incur by reason of acting upon the authorizations and representations set forth herein. I understand that the Direct Cremation Facility and Crematory may seek any and all legal remedies towards the undersigned if there is any form of misrepresentation and/or fraud on my part while holding myself out as and/or acting as the Authorizing Agent.

Signature of Authorizing Agent

Date

Month

Day

Year

To receive a copy of this form you must fill in your email address Please be sure to check your spam/junk folder

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.

Regional Tax*

Northern Nevada

Southern Nevada

Northern Nevada: Reno, Sparks, Carson City
Southern Nevada: Las Vegas, Henderson, Boulder City

Nevada State Funeral Board Fee*

Price:

Merchandise Tax

Price: $0.00

ID Submission

Copy of Valid ID*

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I need assistance and will contact Simple Cremation

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