Authorization Form

I,

Your Name*

, do hereby authorize Simple Cremation to take custody of the remains of

Name of Deceased*

, I certify that I am the legal next of kin or authorized representative and have the right to select any funeral home I desire to take charge of the remains of the above named deceased.

Name of Individual being released, Full Name of Deceased here (can be self if pre-need)*

Electronic Signature:*

Relationship to Deceased*

Phone Number*

Address*

Street Address City State ZIP Code

Authorization To Cremate

Is the individual being cremated?*

Yes
No

Online Arrangements, Authorization to Cremate

The undersigned hereby requests and authorizes Simple Cremation or its assigns in accordance with, and subject to, its rules and regulations, to cremate the remains of Enter Name Below and certifies and represents that he or she has the right to make such authorization and agrees to hold Simple Cremation Services and its assigns harmless from any liability on account of said authorization and cremation.

Insert Name of Deceased*

The undersigned hereby certifies that he/she is the legal custodian of the herein named deceased, having full legal authority to authorize the cremation, and disposition of the cremains of the deceased named herein and, subject to the terms and conditions as set forth in this Authorization, hereby requests and authorizes Simple Cremation or its assigns, hereinafter referred to as Company, in accordance with and subject to its rules and regulations to take possession of, cremate, and make disposition of (type full name of person to be cremated in box below)

Full Name of Person Being Cremated*

A. The undersigned certifies and represents that the remains delivered for cremation are those of the deceased named herein and the undersigned further represents under penalty of perjury that he/she has the right to control the disposition of said remains and hereby agrees to hold the Officers, Agents, and Employees harmless from any and all loss, cost or damages, it or they may suffer or incur by reason of acting upon the order of Authorization above set forth.

B. The Company agrees only to cremate the remains and dispose of the cremated remains as directed herein. No warranties expressed or implied are made, and damages shall be limited to the fee paid.

C. The company shall cremate the remains in a suitable rigid container.

D. The undersigned warrants said remains Please select below if remains contains a pacemaker. or other explosive implant. If said remains contained such a device at time of death, Simple Cremation has been advised of same and authorized to remove and dispose of all such devices.

Select if Remains contain Pacemaker*

Does Contain Pacemaker, additional $75 to remove pacemaker
Does NOT Contain Pacemaker

E. All noncombustible materials delivered with the body will be disposed of at the Company's direction.

F. The undersigned understands 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, Company is hereby authorized to make disposition of the remaining cremains at its discretion, unless otherwise instructed in writing by the undersigned.

G. When cremating, 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. If disposition to family is selected, remains must be picked up within 90 days of cremation. After 90 days, Simple Cremation may scatter the remains.

BY SUBMITTING THIS FORM YOU UNDERSTAND THAT THE CHARGE FOR ALL THE ABOVE SHALL BE PAID IN FULL PRIOR TO COMPLETION OF SERVICES.

Electronic Signature*

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