AUTHORIZATION TO ACCEPT OR DECLINE EMBALMING
TO: ___________________________________________________________________
(Funeral Establishment Name)
RE: ___________________________________________________________________
(Decedent)
Embalming is the addition to, or the replacement of, body uids by chemical
preservatives or the application of chemical preservatives for the temporary
preservation of the body. I understand that embalming is not required by law.
I, ____________________________, do
do not (check one) request embalming.
I understand that for storage or embalming purposes the decedent may be transported
to the following location:
_______________________________________________________________________
(Location Name and Address)
The undersigned hereby represents that he/she has the legal right to control disposition
of the remains of the decedent.
Signed: _____________________________, Relationship to Decedent: _____________
Executed this ____ day of ________________, _____, at ________________________.
(Month) (Year) (City and State)
This section is to be completed by the funeral establishment if authorization to accept or
decline embalming is obtained orally.
The above statement regarding embalming and storage was read and/or provided to
_________________________________, Relationship to Decedent: _______________,
who did did not (check one) authorize embalming at the above named funeral
establishment. Telephone Number: ___________________________
Date and time authorization granted: ________________________________
This section is to be completed by the funeral establishment representative who is
executing this authorization to accept or decline embalming.
I declare under penalty of perjury that the foregoing is true and correct.
Executed this ____ day of ________________, _____, at ________________________.
(Month) (Year) (City and State)
__________________________________ __________________________________
Funeral Establishment Representative (Print Name) Funeral Establishment Representative (Signature)
12-AUTH (rev. 01/16)
CHAPMAN FUNERAL HOMES
CHAPMAN FUNERAL HOMES 1342 East Chapman Avenue Orange, CA 92866
