Fillable AUTHORIZATION FOR CREMATION AND DISPOSITION

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AUTHORIZATION FOR CREMATION AND DISPOSITION

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I/We, the undersigned, certify, warrant and represent that I/we have the full legal right and authority to authorize the cremation, processing and
disposition of the remains of ___________________________________________________________________________________________
Last know address of Deceased _________________________________________________________________________________________
(hereinafter referred to as the “Deceased”),
Date of Death ___________________ Time of Death ___________________ A.M. P.M. Weight ___________________
I/We hereby request and authorize___________________________________________ (hereinafter referred to as the “Funeral Home”) to take
possession of and make arrangements for the cremation of the remains of the Deceased at __________________________________________
(hereinafter referred to as the “Crematory”), and I/we give the Crematory the authority to cremate the remains of the Deceased.
I/We hereby authorize Witness Cremation ________________________________________________________________________________
I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custody of the Funeral Home.
I/We understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the Deceased are returned to
the possession and custody of the Funeral Home. I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains
of the Deceased as follows:
Is special handling required Yes No Describe ________________________________________________________________
_______________________________________________________________________________________________________________
Description of urn or container selected: ________________________________________________ Suitable for shipping: Yes No
Deliver to ___________________________________________________________________________________________ Cemetery
Release to family ______________________________________________________________________________________________
Scattering at sea by Funeral Home or Funeral Home’s agent Scattering by Family _____________________
Ship via _____________________________________________________________________________________________________
To: Name ____________________________________ Address ________________________________________________________
Other _______________________________________________________________________________________________________
The cremation, processing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all
governing laws, the rules, regulations and policies of the Crematory and Funeral Home, and the following terms and conditions:
1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory in a combustible, leak resistant, rigid
cremation container. The Crematory is authorized to remove and dispose of handles, ornaments and any other noncombustible items
attached to the cremation container prior to cremation. In the event the remains of the Deceased are received by the Crematory in a casket
or other container constructed of metal, fiberglass, or other noncombustible materials, I/we authorize the remains of the Deceased to be
removed prior to cremation and placed in a combustible cremation container. I/We further authorize the Funeral Home or Crematory to
make disposition of any such noncombustible casket in any lawful manner it deems appropriate.
2. Mechanical or radioactive devices implanted in the remains of the Deceased (such as pacemakers, etc.) may create a hazard when placed
in the cremation chamber. The Crematory will not cremate any human remains which contain any type of implanted mechanical or
radioactive device. In the event the remains of the Deceased contain such a device, I/we hereby authorize the Funeral Home, its agents
and employees, to remove any such mechanical devices from the remains of the Deceased prior to cremation, and dispose of such items
at its discretion
I/WE HEREBY CERTIFY THAT THE; REMAINS OF THE DECEASED
DOES DOES NOT CONTAIN ANY TYPE OF
IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Please initial one.
Listed below are all implanted mechanical and radioactive devices which the Funeral Home is authorized to remove from the remains of
the Deceased prior to cremation, and dispose of as indicated:
_____________________________________________________ ____________________________________________________
Description of Implanted Device Disposition
_____________________________________________________ ____________________________________________________
Description of Implanted Device Disposition
If no instruction for disposition is given, such items may be disposed of at the discretion of the Funeral Home.
3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will be totally and irreversibly
destroyed by prolonged exposure to intense heat and direct flame. It is understood that the human body burns with the casket, container, or
other material placed in the cremation chamber. Some bone fragments are not combustible at the incineration temperature, and as a result,
remain in the cremation chamber.
AUTHORIZATION FOR CREMATION AND DISPOSITION
NOTICE: THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.
CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
* Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with the United States
Postal Service.
Name of Deceased
Name of Funeral Home
Name of Funeral Home / Crematory
Name and Address of Cemetery
Name of Designated Family Member to Receive Cremated Remains
U. S. Registered Mail*
CHAPMAN FUNERAL HOMES
Initial
GATEWAY CREMATORY
4. During the cremation, the contents of the chamber may be moved to facilitate incineration. I/We authorize the Crematory to open the
cremation chamber during the cremation process and reposition the remains of the Deceased in order to facilitate a complete and thorough
cremation.
5. The cremation chamber is composed of ceramic or other material which disintegrates slightly during each cremation and the product of that
disintegration is commingled with the cremated remains of the Deceased. Nearly all of the contents of the cremation chamber, consisting of
the cremated remains of the Deceased, disintegrated cremation chamber material, and small amounts of residue from previous cremations,
are removed together and crushed, pulverized, or ground to facilitate inurnment or scattering. I/We understand and acknowledge, that even
with the exercise of reasonable care and the use of the Crematory’s best efforts, it is not possible to recover all particles of the cremated
remains of the Deceased, and some residue remains in the cracks and uneven places of the cremations chamber. Periodically, the
accumulation of this residue is removed and interred in a dedicated cemetery property or scattered at sea.
6. Certain items, including, but not limited to, body prostheses, dentures, dental bridgework, dental fillings, jewelry, and other personal
articles accompanying the remains of the Deceased, may be destroyed during the cremation process. I/We further authorize that if any
items, other than the cremated remains of the Deceased, are recovered from the cremation chamber: they shall be separated from the
cremated remains of the Deceased and disposed of by the Crematory: or they shall be returned and placed in the urn or container holding
the cremated remains.
7. I/We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible materials, including, but not
limited to, hinges, latches, nails, and to dispose of such materials.
8. Unless an urn or container suitable for shipment is purchased, the Crematory will place the cremated remains of the Deceased in a container
which is not designated for any type of shipment.
9. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated remains
will be placed in a secondary container and returned to the Funeral Home, together with the primary urn or container.
10. Unless I/We give specific written instructions in this Authorization, the cremation. processing and disposition of the remains of the
Deceased will not be performed in accordance with any particular religious or ethnic customs.
11. In the event the cremated remains of the Deceased remain unclaimed for a period of 30 days, the Funeral Home shall give written notice
to me/us by certified mail at the address(es) indicated below. I/We agree that in the event the cremated remains of the Deceased remain
unclaimed, for a period of 120 days after the date such written notification is mailed, the Funeral Home is authorized and directed to
dispose of the unclaimed cremated remains of the Deceased in any lawful manner it may deem appropriate.
12. I/We agree to indemnify, release and hold the Crematory, Funeral Home, their affiliates, agents, employees and assigns, harmless from any
and all loss, damages, liability or causes of action (including attorneys’ fees and expenses of litigation) in connection with the cremation
and disposition of the cremated remains of the Deceased, as authorized herein, or my/our failure to correctly identify the remains of
the Deceased, disclose the presence of any implanted mechanical or radioactive devices, or take possession of, or make permanent
arrangements for, the disposition of such remains.
13. Except as set forth in this Authorization, no warranties, expressed or implied, are made by the Funeral Home, Crematory, or any of their
respective affiliates, agents, or employees.
14. I/We understand that this document does not contain a complete and detailed description of every aspect of the cremation process. I/We
acknowledge receiving, from the Funeral Home, a copy of the booklet entitled “Cremation Facts” containing additional explanatory
information about the cremation process.
SIGNATURE OF PERSON(S) AUTHORIZING CREMATION AND DISPOSITION
I/We warrant that all representations and statements made herein are true and correct, and that I/We have read and understand the provisions
contained in this document, and that I/We have received the booklet entitled “Cremation Facts”.
Signature _________________________________________________________________________________________________________
Print Name Relationship to Deceased
Address __________________________________________________________________________________________________________
Street City State Zip
Signature _________________________________________________________________________________________________________
Print Name Relationship to Deceased
Address __________________________________________________________________________________________________________
Street City State Zip
WITNESS __________________________________________________________________________ Date: __________. 20 _______
Signature Print Name
__________________________________________________________________________________________________________________
Name of Funeral Home
__________________________________________________________________________________________________________________
Address of Funeral Home
__________________________________________________________________________________________________________________
Name of Funeral Home
__________________________________________________________________________________________________________________
Address of Funeral Home
Tel. No. ( )
Tel. No. ( )
702 East Chapman Avenue, Orange, California 92866 (714) 628-0447
51 East Huntington Drive, Arcadia, California 91006 (626) 445-0447
Chapman Funeral Homes
Chapman Funeral Homes
AUTHORIZATION FOR CREMATION AND DISPOSITION continued
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AUTHORIZATION FOR CREMATION AND DISPOSITION

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Completed 30 August 2021

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