DFS Texas Director: Goodnight Snell Statistical Data Form EDR TCME DO NOT START TER

Transcription

1 DFS Texas Director: Goodnight Snell Statistical Data Form EDR TCME DO NOT START TER First Name Middle Name Last Name Maiden Name Suffix AKA s Full Name of Deceased Date of Death Time of Death AM PM Gender Date of Birth Age Place of Birth Married Widowed Divorced Never Married Unknown SSN Surviving Spouse (with maiden) Residence Address Apt/Lot# City/Town County State Zip Inside City Limits? Y N Father s Name Mother s Name (maiden) If death occurred in a hospital: Inpatient ER/Outpatient DOA Hospital/Facility Name If death occurred somewhere other than a hospital: Hospice Facility Nursing Home Decedent s Home Other Address City & Zip Inside City Limits? YES NO If No give Precinct Number County: TRAVIS BEXAR HARRIS Other Education: 8 th grade or less 9 th 12 th no diploma HS or GED Some College no Degree Associate s Bachelor s Masters Doctorate Unknown Armed Forces: Y N Branch: USMC ARMY AIR FORCE NAVY CG Texas Peace Officer: Y N Is the decedent of Hispanic Origin? (Check the box that best describes whether the decedent is Spanish/Hispanic/Latino. Check the No box if the decedent is not Spanish/Hispanic/Latino. No, not Spanish, Hispanic/Latino Yes, Mexican, Mexican American, Chicano Yes, Puerto Rican Yes, Cuban Yes, other Spanish/Hispanic/Latino (specify) Decedent s Race (Check one or more races to indicate what the decedent considered himself or herself to be) White Black or African American American Indian or Alaska Native (Name of the enrolled or principal tribe) Asian Indian Chinese Filipino Japanese Korean Vietnamese Samoan Other Asian (Specify) Native Hawaii Guamanian or Chamorro Other Pacific Islander (Specify) Other (Specify) Occupation Industry

2 Method of Disposition: Cremation Crematory: Camero Crematory Crown Cremation Center Other Lone Star Mortuary & Cremation Informant Relationship Mailing Address City State Zip Home Phone Cell Phone address Certifier: Certifying Physician TCME (do not start TER) BCME HCME Justice of the Peace Name of Certifier Address of Certifier ph. Is Certifier on TER? Y N JP/ME Crem. Auth. needed? Y N BTP needed? Y N Number of DC s Registrar 1-21, 2-25, 3-29, 4-33, 5-37, 6-41, 7-45, 8-49, 9-53, 10-57, 11-61, 12-65, 13-69, 14-73, 15-77, , 18-89, 19-93, 20-97, , , , , , , , , , Revised 11/4/2018

3 Texas Funeral Service Commission Form b AUTHORIZATION TO EMBALM AT FUNERAL ESTABLISHMENT OR OTHER LOCATION Name of Licensed Funeral Establishment : Legends Funeral Home Name of Deceased Date of Death The undersigned, understanding that embalming is not required by law except in certain special cases, authorizes the funeral establishment to utilize a licensed facility under the same general ownership and management or use licensed embalmers as agents or independent contractors or a commercial embalming establishment to care for, embalm, and prepare the body of the deceased. The funeral establishment accepts the responsibility of revealing, upon request, to the next-of-kin or person responsible for making final disposition arrangements, the name, address, and license number of the facility where embalming occurred and the name and license number of the embalmer and any provisional licensee or mortuary student who assisted under the embalmer s direct supervision. The undersigned authorizes and directs the funeral establishment, including apprentices (provisional licensees), and mortuary students under the direct supervision of a licensed embalmer employed by the funeral establishment, and the funeral establishment s employees, independent contractors, and agents to care for, embalm and prepare the body of the decedent. The undersigned acknowledges that this authorization encompasses permission to embalm at the funeral establishment or at another facility equipped for embalming, including a school or college of mortuary science. If you authorize embalming, you also authorize the charge for embalming. Date Signed Signature of next-of-kin or Person Responsible for making arrangements for final disposition NOTE: Mortuary Students may only participate in embalming if permission is in writing and in the possession of the Licensed Embalmer at the time of the procedure. If Authorization for embalming is oral, complete the following: Location of embalming disclosure was discussed with next-of-kin or person responsible for making arrangements. Authorization to embalm received from Relationship to Deceased Time a.m. or p.m. Date Received by If no authorization can be obtained, complete the following: I hereby acknowledge that Legends Funeral Home has made a reasonable effort over a period of at least three hours to obtain authorization to embalm the deceased. I take full responsibility for performing embalming without permission. Times contact with family attempted: Signature and License # of Embalmer The undersigned, who represents the deceased, hereby declares that having the legal authority to do so, refuses to give permission to embalm the above-named deceased individual. Signature Date

4 Crown Cremation Center 801 S. Frio St. San Antonio, Texas Phone (210) Fax (210) AUTHORIZATION FOR CREMATION Cremation Number:- _ Date: The undersigned hereby requests and authorizes Crown Cremation Center (hereinafter referred to a:; "Crematory") located at 801 S, Frio St, San Antonio, TX in accordance with and subject to their rules and regulations, to cremate the remains of: Name: Gender Age Last PennanentAddress: City State Zip Date of Birth Date of Death Time of Death _ () a.m. () p.m. Place of Death Cause of Death Religious Affiliation Name of Parish Casket Type: Wood Metal or Alternative Container Embalmed: Yes No _ The undersigned further acknowledges that the death ( ) was ( ) was not, due to an infectious or contagious disease, The approximate body weight is Authority of Authorizing Agent r (We), the undersigned, hereby certify that I (We) are the closest living next of kin of the decedent and that I (Yve) are related to the decedent as his/her or that I (we) serve in the capacity of _, to the decedent, that I (we) have charge of the remains of the d edent and as such possess full lega'j authority and power, according t.o the laws of the State of Texas, to execute th.e authorization form and to arrange for the cremation and disposition of the cremated remains of the decedent. I am / We are 0:ot aware of any person with superior or equal priority right to arrange, control, or authorize the cremation and disposition of the remains of the Decedent but in the event there is another person who has equal priority right to me / us, I / We have made all reasonable efforts but failed to contact that person _and believe that person would not object to the cremation. Limitation of Liability As the authorizing agent(s), I (Wei hereby agree to indemnify, defend, and hold harmless Crown Cremation Center and funeral home, its officers, agents, and employees from any and all claims, demands, causes or causes of action, and suits of every kind, nature and description, in law or equity, including any legal fees, costs and expenses of litigation, arising as a ult of, based upon or connected with this authorization, including the failure to properly idenfify the decedent or the human remains transqiitted to Crown Cremation Center. tl:te processing, shipping and final disposition of the decedent or the dee{:dent's cremated remains, the failure to take possession of or make proper arrangements for the final disposition of the cremated remains, any damage due to hannful or explodable implants, claims brought by any other person(s) claiming the right to control the disposition of the decedent or the decedent's cremated remains, or any other action performed by Crown Cremation Center, its officers, agents, or employees pursuant to this authorization, excepting only acts of willful negligence, Crown Cremation Center, in conducting the cremation is relying on the accuracy of all the information and representation of the parties authorizing the cremation, and the stated representing funeral home / mortuary. Accordingly, the obligations of Crown Cremation Center shall be limited to the cremation of the decedent as authorized in this document No warranties express or implioo are made and damages shall be limited to the amount of the cremation fee paid, Note: This is a legal document. Read this document carefully before signing. It contains important provisions concerning Cremation and Disposition, Cremation is irreversible and final. Viewing or Senice Have arrangements been made by the Authorizing Agent(s) for a viewing of the Decedent or a service before cremation ( ) Yes ( ) No. If yes please giye the date and time of the viewing or service Date: Time: Page 1 of 4 White - Crematory Yellow- Ffle Pink- Famlly

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8 LEGENDS TRI-COUNTY FUNERAL SERVICES 101-B Centerpoint Road - San Marcos, Texas (512) , Fax (512) FUNERAL PURCHASE AGREEMENT Name of Deceased Date of Death Statement Date Charge to Telephone Buyers Home Address City State Zip Code Charges are only for those items that you have selected or that are required. If we are required by law or by cemetery or by crematory to use any items, we will explain the reasons in writing below. If you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve if you selected arrangements such as a direct cremation or immediate burial. If we charged for embalming, we will explain why below. PROFESSIONAL SERVICE SELECTED G. SPECIAL SERVICES F. MERCHANDISE 4a. Direct cremation for deceased that weighs 300 pounds or less $ 4. Urn(s) $ 7. Other $ TOTAL OF MERCHANDISE SELECTED $ 4b. Direct cremation for deceased that weighs 301 to 500 pounds $ H. CASH ADVANCES 8a. Certified copies of death certificates $ b. Add l certified $4.00 each $ We charge you for our service in obtaining those items marked with an 10a. Other: USPS Priority Express 10b. Other: Medical Examiner Permit Fee TOTAL OF CASH ADVANCES $ $ $ SUMMARY OF CHARGES SPECIAL SERVICES MERCHANDISE SELECTED CASH ADVANCES TOTAL OF ALL CHARGES (Balance Due) $ $ $ $ METHOD OF PAYMENT: Less: Credit Card(s) Other: $ BALANCE $ Explanation of Certain Charges: Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain the reasons in writing here. Cemetery/Crematory: Crematory requires an Alternative Container to encase the remains for cremation. WARRANTIES: The only warranties, expressed or implied, granted in connection with goods sold with this funeral service are the express written warranties, if any, extended by the manufacturers thereof. No other warranties and no warranties of merchantability or fitness for a particular purpose are extended by seller. I agree that any monies assigned above shall be paid to you within 60 days of the date of this contract. Upon your giving me at least five (5) days prior written notice that any monies due under the assignment(s) described above have not been paid to you as promised, you can require that any such unpaid amount(s) previously credited to my account be paid by me at once. Charges are made only for those items that are used. If the type of funeral selected requires extra items, we will explain the reasons in writing on this contract. In the event I wish to complain or question any area of your service, I may contact you at my convenience. If any complaint cannot be resolved, I may also contact the Texas Funeral Service Commission, P.O. Box 12217, Austin, Texas Telephone Number: (888) , Fax Number: (512) TERMS: The Unpaid Balance set out above will be due and payable on the Due Date set out above. A FINANCE CHARGE of 1 1/2 per month (ANNUAL PERCENTAGE RATE 18 ) will be added to all past due amounts not paid on or before the Due Date set out above. If this agreement is placed in the hands of an attorney and/or agency for collection, I (we) agree to pay reasonable attorney s fees and/or collection costs. By his (her) signature, buyer(s) in addition to authorizing seller to conduct the funeral, perform the service, furnish the materials, and incur the charges specified within this agreement, on the terms and conditions set forth, acknowledges that prior to the execution of this agreement, a printed or typewritten list of retail price of funeral services and funeral merchandise offered by seller was made available to buyer(s). ACCEPTED FOR SELLER: Executed this day of, 20. By: Signature of Funeral Director who made the arrangements Signature (1) Buyer Signature (2) Co-Buyer

9 Crown Cremation Center 801 S. Frio St. San Antonio, TX Legends Funeral Home 101-B Centerpoint Rd., San Marcos, TX John Goodnight/Jonathan Snell

10 City of San Antonio Office of the City Clerk Vital Records Division Funeral Home Request For BURIAL TRANSIT PERMITS All deaths must be entered in TER have San Antonio City Clerk designated as the Local Registrar before the requests can be filled. This option cannot be left blank [TAC l81.2{b)j. Fax requests to Deceased: Date of Death: Funeral Home: Requested by: Print Name Signature Address: City: TX ZIP: EDR #: Date Requested: Choose One: HOLD for pick up: FAX: FAX NUMBER: Revised 10/30/2015

11 BEXAR COUNTY MEDICAL EXAMINER S OFFICE RANDALL E. FROST, M.D. CHIEF MEDICAL EXAMINER 7337 Louis Pasteur Drive, San Antonio, Texas (210) FAX (210) or (210) Accredited by the National Association of Medical Examiners AUTHORIZATION TO RELEASE REMAINS TO: Bexar County Medical Examiner s Office Legends Funeral Home FROM: (Funeral Home Name) DATE: I,, hereby certify and represent that I am the (Print Name) (Relationship to decedent) and legal next of kin of:, AKA, (Name of Decedent as it appears on Social Security Card or birth certificate),. (Date of Birth) (Social Security Number if applicable) I, the undersigned, further agree to release the Bexar County Medical Examiner s Office from any liability on account of the said authorization. It is my desire and request that you release the personal effects and the remains of the decedent to Legends Funeral Home. (Name of Funeral Home) Signature of Next of Kin: Relationship Address: Telephone Number: Witnessed by: Date: Revised: H:\Forms\Authorization to Release Remains

12 TRAVIS COUNTY OFFICE OF THE MEDICAL EXAMINER 1213 Sabine Street PO Box 1748 Austin, TX Tel: (512) Fax: (512) J. KEITH PINCKARD, MD, PhD D-ABP, F-ABMDI CHIEF MEDICAL EXAMINER Body Release to Funeral Home DATE FAX: (512) This authorizes the Medical Examiner s Office, Travis County, Texas, to release the remains of to Funeral Home And Mortuary Service if applicable. Please complete Funeral Home information below: Address: City: State: Zip Code: Phone # Fax# Authorization is also given to the above named Funeral Home, or its designated agents, to remove the said deceased to their place of business to care for, and prepare for disposition in accordance with professional standards. The above named Funeral Home is authorized to receive personal property: Yes No Signature: Print Name: Relationship: SUBMIT THIS DOCUMENT TO THE MEDICAL EXAMINER S OFFICE UPON REMOVAL OF THE DECEASED.

13 Body Removal Permit DATE: This form authorizes Central Texas Autopsy, PLLC, to release the remains of: (DOB: ) to: Name of Funeral Home or Mortuary Service Funeral Home/Mortuary Service Information: Address: City: State: Zip Code: Phone No: Fax No: This form authorizes the above named Funeral Home/Mortuary Service, or its designated agents, to remove the above named deceased to their place of business to care for, and/or prepare for disposition in accordance with professional standards. The above named Funeral Home/Mortuary Service is authorized to receive the valuables associated with the deceased: Yes ( ) No ( ) Signature: Print Name: Title or Relationship to deceased: This form must be submitted to Central Texas Autopsy, PLLC, prior to or upon removal of the deceased from our premises.