[Funeral Home Name]

License No.: [License Number]

I, the undersigned, hereby authorize [Funeral Home Name] to proceed with the disposition of the remains of the deceased, as specified below:

1. Deceased Information

• Full Name of Deceased: ______________________
• Date of Death: ______________________
• Place of Death: ______________________

2. Disposition Options (Choose ONE and initial)

• [ ] Burial: I authorize burial of the remains.
• [ ] Cremation: I authorize cremation of the remains.
• [ ] Donation: I authorize donation of the remains for medical or scientific purposes.
• [ ] Other (Specify): ______________________

3. Release of Remains

• [ ] Release to Family Member/Representative:

  • Name: ______________________
  • Relationship: ______________________
  • Address: ______________________
  • Phone: ______________________

• [ ] Release to Cemetery/Mausoleum:

  • Name of Place of Interment: ______________________
  • City/County & State: ______________________

• [ ] Delivery/Shipment:

  • Location: ______________________
  • City and State: ______________________

4. Liability Waiver

I understand that [Funeral Home Name] is not liable for any changes in state laws, regulations, or taxes that may impact the disposition of the remains. I release them from any liability arising from unforeseen circumstances related to this authorization.

5. Governing Law

This authorization shall be governed by the laws of the state of [State Name].

6. Signatures

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 disposition.

Client’s Signature: ______________________ Date: ______________________

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