[Funeral Home Name]

License No.: [License Number]

I, the undersigned, hereby authorize [Funeral Home Name] to perform the following services and activities related to the funeral arrangements for the deceased:

1. Funeral Services:

   • [ ] Traditional Funeral Service
   • [ ] Memorial Service
   • [ ] Graveside Service
   • [ ] Other (Specify): ______________________

2. Embalming:

   • [ ] I authorize embalming for preservation purposes.
   • [ ] I decline embalming.

3. Cremation:

   • [ ] I authorize cremation.
   • [ ] I decline cremation.

4. Burial:

   • [ ] I authorize burial in the following location: ______________________
   • [ ] I decline burial.

5. Other Related Activities:

   • [ ] Viewing of the deceased
   • [ ] Transportation of the deceased
   • [ ] Use of a hearse
   • [ ] Preparation of the body
   • [ ] Other (Specify): ______________________

Liability Waiver and Acknowledgments

1. I understand that the funeral services and related activities are subject to state and local laws and regulations.

2. I release [Funeral Home Name] from any liability arising from unforeseen circumstances, including changes in pricing, availability, or legal requirements.

3. I acknowledge that any changes to the selected services or activities may affect the final cost.

Signature and Consent

By signing below, I confirm that I am the next-of-kin or legal representative of the deceased, and I authorize [Funeral Home Name] to proceed with the specified services and activities.

Client’s Signature: ______________________ Date: ______________________

Witness’s Signature (if applicable): ______________________ Date: ______________________