Pre-Need Application – Simple Cremation

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Pre-Need Cremation Package
Price:
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VITAL STATS INFORMATION
(All information below pertains to the deceased.)
Deceased Name*
First Middle Last
Gender*
ETHNICITY
Race
Hispanic Origin
If Other Description
Age*
Date of Birth*
Month
Day
Year
State of Birth*
Citizen of what Country*
Years in School*
Number of Years in School
Marital Status*
Surviving Spouse
If female, please provide maiden name
First Middle Last
Social Security Number*
Usual Occupation

Cannot use "Retired" for Occupation field.
Kind of Business or Industry
Ever in the US Armed Forces
Applicant's Home Address*
Street Address City State ZIP Code
County in which the applicant lives*
Father*
First Middle Last
Mother*
Please provide maiden name
First Middle Last
Your Name/Signatory*
First Middle Last
Relationship to Applicant (can be self)*
Address of Signatory*
Street Address City State ZIP Code
Signatory Telephone Number*
Current Total
$0.00

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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?
Signature*
Your Name/Signatory*
First Middle Last

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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

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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*
- A - Explorer Sunset Scattering Urn $65.00 + tax
- B - Rosewood Urn Tree of Life (wood) $99.00 + tax
- C - Green Tree of Life Urn (Brass) $339.00 + tax
- D - Explorer Desert Dusk Scattering Urn $65.00 + tax
- E - Simple Urn $40.00 + tax
- F - Rosewood Urn Tower Cross (wood) $99.00 + tax
- G - Explorer Cherry Blossom Scattering Urn + Tax
For additional options and personalization please call: Southern Nevada: 702-273-3844 Northern Nevada: 775-324-3720
Do you want your remains shipped?*
- Yes, ship remains
  (Additional $150)
- I will pick up remains
Person(s) authorized to pick up remains
Multiple names may be entered separated by a comma (,)
Shipping Address
Street Address Address Line 2 City State ZIP Code
Current Total
$0.00

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Authorization Form
Deceased/Pre-Need Applicant Name*
First Middle Last
Today’s Date*
Month
Day
Year

Today’s Time*

: Hours

Minutes

AM/PM

Date of Death
Month
Day
Year

Your 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.
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. (Alternative cremation container is included in the plan.)
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 deceased 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 deceased 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 deceased;
An adult son or daughter of the deceased;
Either parent of the deceased;
An adult brother or sister of the deceased;;
A grandparent of the deceased;
A guardian of the person of the deceased 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 or direct cremation facility as the remains of the Deceased;
Identification Viewing

Request an Identification Viewing

No Viewing
An arranger will contact you to schedule the viewing.
Does your loved one have a pacemaker or other battery powered implant?*

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:
Did the death occur from a communicable or otherwise dangerous disease?*
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.
Consent*
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 of Signatory*
Street Address City State ZIP Code

Relationship*

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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.
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
Current Total
$0.00
ID Submission
Contact Email*

Copy of Valid ID*

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I need assistance and will contact Simple Cremation
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VITAL STATS INFORMATION

(All information below pertains to the deceased.)

ETHNICITY

CREMATION TIMELINE STATEMENT AND ACKNOWLEDGEMENT

CREMATION TIMELINE STATEMENT AND ACKNOWLEDGEMENT

Death Certificates

Authorization Form

ID Submission

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