Pre-Plan – Simple Cremation

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Client Information

You may complete this form for yourself or a loved one who plans to be cremated.

Full Name*

Address*

Street Address City State ZIP Code

County*

Social Security Number*

Date of Birth*

State of Birth*

US Citizen*

Yes
No

If No: What Country*

Sex*

M
F

Occupational Information

Kind of Industry or Business*

Primary Occupation (Note: Retired is not a valid entry)*

Marital Status*

Spouse Name

First Middle Last

*Last Name Must be Maiden If Wife

Education

Number of Years Completed*

Highest Degree Completed*

Race

Race*

Please specify Hispanic origin*

Cuban
Mexican
Puerto Rican

Parent Information

Father's Name*

First Middle Last

Mother's Name*

First Middle MAIDEN

Veteran*

No
Yes, if yes you will need to provide a valid DD214

Next Of Kin

Immediate Next of Kin*

Next of Kin Relationship*

Next of Kin Telephone Number*

Next of Kin Address*

Street Address City State ZIP Code

Person In Charge of Arrangements

Informant:*

Relationship*

Phone*

Address*

This is the address any ordered Death Certificates will be mailed to.

Street Address City State ZIP Code

Hospice Care

Is/Was the decedent under hospice care*

Yes
No

What is the name of the hospice used*

Authorization Form

I,

Client Name*

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

Name of person being cremated*

, 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 person being cremated.

Name of Individual to be cremated.*

Electronic Signature:*

Relationship to Client*

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.

Name of Client*

The undersigned hereby certifies that he/she is the legal custodian of the herein named, having full legal authority to authorize the cremation, and disposition of the cremains of the 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 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.

Does the Individual Have a Pacemaker*

Has a Pacemaker, additional $75 to remove pacemaker
NO 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.

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*

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

Client Information

Occupational Information

Education

Race

Parent Information

Next Of Kin

Person In Charge of Arrangements

Hospice Care

Authorization Form

Authorization To Cremate

Online Arrangements, Authorization to Cremate

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