CREMATION AND DISPOSITION AUTHORIZATION

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Everett Sutton
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1 For Crematory Use Only No. Date: Time: CREMATION AND DISPOSITION AUTHIZATION The State of Missouri requires that this Authorization Form be completed and signed prior to the cremation. Please read it carefully and ask us any questions you may have. Cremation is an irreversible and final process. It is important that you understand the cremation process that is described in Section 9 of this Authorization Form prior to signing it. We want you to fully understand the information provided in this Authorization Form, so we will be pleased to answer any questions about the cremation process or the other information in this Form. THE AUTHIZATION IS NOT A CONTRACT F CREMATION SERVICES. A SEPARATE CONTRACT CONTRACTS WILL BE REQUIRED TO PURCHASE THE SERVICES OF THE FUNERAL HOME AND/ CREMATY. (Print all information except signatures.) 1. IDENTIFICATION OF THE DECEDENT Name of Decedent: Date of Death: Time: Place of Death: Sex: Age: DOB: SS#: Last Residence of Decedent: Place of Birth: Death Certificate Filing Status: I hereby state upon my oath that prior to the cremation of the above named person that: A completed death certificate has been filed with the local registrar where the death occurred; or Written authorization to cremate the body has been received from the medical examiner/coroner or physician who will be certifying the cause of death. Signature: License Number: Time: Date: Designated Person To Pick Up Cremated Remains: Cremated Remains to be placed in: Other: Funeral home to inter cremated remains at: Ship Cremated Remains To: Section: Lot: Grave: Address: State: Zip: 1

2 BECAUSE CREMATION IS IRREVERSIBLE, IDENTIFICATION OF THE DECEDENT IS REQUIRED BY ONE OF THE FOLLOWING METHODS: The Authorizing Agent has viewed the remains and positively identified them as the body of the Decedent The personal representative of the Authorizing Agent has viewed the remains and positively identified them as the body of the Decedent. The Authorizing Agent has authorized the Funeral Home to photograph the remains and the Authorizing Agent has positively identified the photograph as that of the Decedent. Identification has been made by the Coroner, Health Department, Law Enforcement, or other governmental entity and said identification is accepted by the Authorizing Agent. 2. FUNERAL HOME AND CREMATY Name of Funeral Home: Address: Crematory: Address: Name of the Funeral Director who obtained this Authorization: 3. IDENTIFICATION OF AUTHIZING AGENT Name of Authorizing Agent: Type or Print Name Only Address: Telephone: Relationship: (Choose and enter letter from below): The Authorizing Agent represents that the relationship between the Authorizing Agent and the Decedent is as follows: (a) (b) (c) (d) An attorney in fact designated in a durable power of attorney wherein the deceased specifically granted the right of sepulcher over his or her body to such attorney in fact; For a decedent who was on active duty in the United States military at the time of death, the person designated by such decedent in the written instrument known as the United States Department of Defense Form 93, Record of Emergency Data, in accordance with P.L , Section 564, 10 U.S.C. Section 1482; The surviving spouse; Any surviving child of the deceased. If a surviving child is less than eighteen years of age and has a legal or natural guardian, such child shall not be disqualified on the basis of the child's age and such child's legal or natural guardian, if any, shall be entitled to serve in the place of the child unless such child's legal or natural guardian was subject to an action in dissolution from the deceased. In such event the person or persons who may serve as next-of-kin shall serve in the order provided in subdivisions (5) to (9) of this subsection; (e) (i.) (ii.) (iii.) Any surviving parent of the Deceased; or If the Deceased is a minor, a surviving parent who has custody of the minor; or If the deceased is a minor and the deceased's parents have joint custody, the parent whose residence is the minor child's residence for purposes of mailing and education. 2

3 (f) (g) (h) (i) Any surviving sibling of the Deceased. The next nearest surviving relative of the deceased by consanguinity or affinity; Any person or friend who assumes financial responsibility for the disposition of the deceased's remains if no next-of-kin assumes such responsibility; The county coroner or medical examiner; provided however that such assumption of repsonsibility shall not make the coroner, medical examiner, the county, or the state financially responsible for the cost of disposition. 4. AUTHITY OF AUTHIZING AGENT As Authorizing Agent, I represent that I have the right to authorize the cremation of the Decedent's remains and I am initialing one of the following two statements accordingly: As Authorizing Agent, I have filled in Section 3 above. I understand that any living person who meets the qualifications of any level above the one I filled in would have a superior right to act as the Authorizing Agent. I certify that I do not have actual knowledge of the existence of any living person who has a superior right to act as the Authorizing Agent. As Authorizing Agent, I am aware of a living person or persons who have a superior or equal priority right to act as Authorizing Agent. I have either contacted such person(s) and they have no objections to the cremation of the Decedent or I have been unable to contact such person(s) after making reasonable efforts to do so. In the latter case, I certify that I have no reason to believe that the person(s) with the superior or equal priority right would object to the cremation of the Decedent. 5. PACEMAKERS, IMPLANTS, AND PROSTHESES Pacemakers, radioactive, silicon or other implants, mechanical devices or prostheses may create a hazardous condition when placed in the cremation chamber and subjected to heat. As Authorizing Agent, I have listed below all devices (including mechanical, prosthetic, implants, or materials), which may have been implanted in or attached to the Decedent. Description of Devices: Please initial one of the following statements: The remains of the Deceased do not contain any of the Devices described above. As Authorizing Agent, I instruct the Funeral Home to remove each Device listed above and to charge for its services in making or arranging for such removal. Unless indicated directly below, the Funeral Home is to dispose of all such Devices. The Devices listed are to be removed and returned to the Authorizing Agent: 6. CASKET ALTERNATIVE CONTAINER The remains are to be cremated in a combustible casket or alternative container that is capable of being completely closed, is resistant to leakage or spillage, is sufficiently rigid to be handled easily, and provides protection for the health and safety of Crematory and Funeral Home personnel. The Crematory is authorized to inspect the casket or alternative container, including opening it if necessary. In the event that the casket or container does not meet the above requirements, the Crematory will notify the Authorizing Agent. Many caskets that are comprised primarily of combustible material also contain some exterior parts (decorative handles or rails) that are not combustible and that may cause damage to the cremation equipment. As Authorizing 3

4 Agent, I authorize the Crematory, in its discretion, to remove and discard the non-combustible materials. I understand that some crematories will not accept metal or fiberglass caskets. I further understand that the casket or alternative container will be consumed as part of the cremation process. Casket or Alternative Container Selected: Enter Name of Container 7. MULTIPLE CREMATIONS Under Missouri law, the remains of more than one decedent may not be simultaneously cremated in the same cremation chamber unless the decedents to be cremated were related or were, any time during the one-year period preceding their deaths, living in a common law marital relationship or cohabitating. Unless authorized on the reverse side, the Deceased's remains shall be individually cremated. If you desire a multiple cremation you must initial below. As Authorizing Agent, I authorize the simultaneous cremation of the remains of the Deceased with. I certify that this multiple cremation meets the legal requirements set forth above. Name of Other Decedent: 8. WITNESSES Witnessing a cremation can be an emotional experience. Witnesses are assuming the risks involved and fully release the Funeral Home and Crematory from any liability. To the extent permitted by the Crematory, the persons listed on the reverse side are authorized to be present at the cremation room prior to and during the cremation of the Deceased's remains and during the removal of the cremated remains from the cremation chamber. If you desire witnesses you must inital below and list their names. No Witnesses. List Names of Witnesses: 9. THE CREMATION PROCESS The cremation of the Deceased's remains may take place before or after ceremonies to memorialize the Decedent. Cremation is performed to prepare the remains of the Deceased for final disposition. It is carried out by placing the Deceased's remains in the casket or alternative container, which is then placed into a cremation chamber or retort where they are subjected to intense heat and flame. All cremations are performed individually unless noted otherwise in Section 7 above. During the cremation process, it may be necessary to open the cremation chamber and reposition the remains of the Deceased in order to facilitate a complete and thorough cremation. Through the use of suitable fuel, the incineration of the container and its contents is accomplished and all substances are consumed or driven off, except bone fragments (calcium compounds) and metal (including dental gold and silver and other non-human materials) as the temperature is not sufficient to consume them. Due to the nature of the cremation process, any personal possessions or valuable materials, such as dental gold or jewelry (as well as any body prostheses or dental bridgework) that are left with the remains and not removed from the casket or container prior to cremation may be destroyed or if not destroyed, will be disposed of by the Crematory. The Authorizing Agent understands that arrangements must be made with the Funeral Home to remove any such possessions or valuables prior to the time that the remains of the Decedent are transported to the Crematory. 4

5 Following a cooling period, the cremated remains, which will normally weigh several pounds in the case of an average-size adult, are then swept or raked from the cremation chamber. Although the Crematory will take reasonable efforts to remove all of the cremated remains from the cremation chamber, it is impossible to remove all of them, as some dust and other residue from the process will be left behind. In addition, while every effort will be made to avoid commingling, inadvertent and incidental commingling of minute particles of cremated remains from the residues of previous cremations is a possibility, and the Authorizing Agent understands and accepts this fact. After the cremated remains are removed from the cremation chamber, all non-combustible material (insofar as possible) such as dental bridgework and hinges, latches, and nails from the container will be separated and removed from the human bone fragments by visible or magnetic selection. The Crematory is authorized to dispose of these materials with similar materials from other cremations in a non-recoverable manner, so that only human bone fragments will remain. When the cremated remains are removed from the cremation chamber, the skeletal remains often will contain recognizable bone fragments. Unless otheriwse specified, after the bone fragments have been separated from the other material, they will be mechanically pulverized. The process of crushing or grinding may cause incidental commingling of the remains with the residue from the processing of previously cremated remains. These granulated particles of unidentifiable dimensions, which are virtually unrecognizable as human remains, will then be placed into a designated container. 10. AUTHIZATION TO CREMATE, PROCESS AND PULVERIZE As Authorizing Agent, I have read and understand the description of the cremation process contained in #9 above and authorize the cremation, processing and pulverization of the remains of the Decedent. I further authorize the Funeral Home to deliver the Decedent's remains to the Crematory for the purpose of the cremation. 11. DISPOSITION OF THE REMAINS The disposition of the cremated remains shall be handled in accordance with the provisions of Chapter of the Revised Statutes of Missouri which provide, in part, that the cremated remains will be disposed of in accordance with the cremation contract or delivered to or as directed by the person or entity that contracts for the cremation. THE PERSON THAT CONTRACTS F THE CREMATION HAS THE RIGHT TO POSSESSION, TO DETERMINE THE DISPOSITION, OF THE CREMATED REMAINS. (a) Urn or Temporary Container: After the cremated remains have been processed, they will be placed in the urn contracted for in the cremation contract or, if an urn is not provided to the Crematory, in a temporary container provided by the Crematory. The Authorizing Agent acknowledges that it is impossible to recover all of the dust and residue from the cremation and processing. In the case of an adult, it is recommended that the urn or temporary container be a minimum size of 200 cubic inches. In the event of the urn or temporary container is insufficient to accommodate all of the cremated remains, the excess will be placed by the Crematory in a secondary container. This secondary container will be kept with the urn or the temporary container and handled according to the final disposition instruction set forth in Section (b) below; provided, however, that the secondary container may not be designed for shipping. All urns or containers provided to the Funeral Home or Crematory must be appropriate for shipping. The Authorizing Agent directs the Crematory to use the specified urn or container listed above. 5

6 (b) Disposition: Following the cremation, the Authorizing Agent directs the Crematory and/or Funeral Home to undertake the actions set forth in this document to arrange the disposition of the cremated remains of the Deceased. If the cremated remains are shipped at any time, the Authorizing Agent directs that the Crematory or Funeral Home utilize registered U.S. mail with a return receipt or a shipping service that uses an internal system for tracing the location of the cremated remains during shipment and requires a signed receipt of the person taking delivery of the cremated remains. The Authorizing Agent understands that if no arrangements for the disposition, release or shipment of the cremated remains are made in this Authorization after 90 days from the date of cremation, the Crematory and/or the Funeral Home may bury, inter or scatter the cremated remains in a scatter garden or pond, columbarium or other place formally dedicated for such purpose, or deliver the cremated remains to any "next-of-kin" as set out in section 194 of the Revised Statues of Missouri. 12. PERSONAL PROPERTY All personal property and effects delivered with the remains of the Deceased to the Crematory, including jewelry, clothes, hair pieces, dental bridgework, eyeglasses, and shoes, will be destroyed in the cremation process or otherwise discarded by the Crematory, in its sole discretion, unless specific instructions for delivery to Authorizing Agent are given below. Items to be delivered to Authorizing Agent: 13. TIME OF CREMATION If the remains are not embalmed and if the cremation is not to occur immediately upon delivery of the remains to the Crematory, the Crematory will place the remains in a refrigerated facility for which there may be a daily charge. Decedent's remains are to be embalmed (initials) are not to be embalmed (initials) Please initial one of the following: The Crematory may perform the cremation of the Decedent's remains at a time and date as its work schedule permits and without any further notification to the Authorizing Agent. The Crematory is to use its best efforts to schedule the cremation in accordance with the schedule set forth below: Date: Time: 14. PAYMENT F SERVICES The Authorizing Agent acknowledges that the cremated remains will not be disposed of or delivered as set out in paragraph 11 until full payment is made for the goods and services contracted for in the cremation contract. 6

7 15. CERTIFICATION AND INDEMNIFICATION The Authorizing Agent acknowledges that the Funeral Home and Crematory are relying upon the representations being made by the Authorizing Agent in this authorization. The Authorizing Agent certifies that all of the information and statements contained in the Authorization are accurate and no omissions of any material fact have been made. The Authorizing Agent agrees to indemnify and hold harmless the Funeral Home and the Crematory, their officers, directors, employees and agents from any and all claims, demands, actions, causes of action or suits of any kind or nature whatsoever, including, but not limited to, any legal fees arising out of or resulting from the Funeral Home's and the Crematory's reliance on or performance consistent with the directions, statements, representations and agreements contained in the Authorization. Executed at, this, day of, 20. Type or Print Name of Authorizing Agent: Signature of Authorizing Agent: Witness: Supplemental Signatures Attached NOTIFICATION If this line is initialed, it indicates that the cause of death of the Deceased was from a disease declared by the Department of Health and Environment to be infectious, contagious, communicable or dangerous to the public health. 16. FINAL DISPOSITION OF CREMAINS By my signature, I have received the cremated remains of the deceased named on this form. Signature: Date Received: Funeral Home Name: Address: By my signature, I have delivered the cremated remains of the deceased named on this form to: Location: Signature: Date Delivered: If the cremated remains were delivered or placed other than by an employee of (Name of Establishment) The name of the person or company who made the delivery or placement or the name of the business by which the cremated remains were shipped along with the receipt number is shown below. Name of person making the delivery or placement of cremains: Name of business by which cremated remains were shipped: Name: Receipt or Tracking Number: 7

8 Missouri Revised Statutes Chapter 194 Death--Disposition of Dead Bodies Section August 28, 2016 Right of sepulcher, the right to choose and control final disposition of a dead human body As used in this section, the term "right of sepulcher" means the right to choose and control the burial, cremation, or other final disposition of a dead human body. 2. For purposes of this chapter and chapters 193, 333, and 436, and in all cases relating to the custody, control, and disposition of deceased human remains, including the common law right of sepulcher, where not otherwise defined, the term "next-of-kin" means the following persons in the priority listed if such person is eighteen years of age or older, is mentally competent, and is willing to assume responsibility for the costs of disposition: (1) An attorney in fact designated in a durable power of attorney wherein the deceased specifically granted the right of sepulcher over his or her body to such attorney in fact; (2) For a decedent who was on active duty in the United States military at the time of death, the person designated by such decedent in the written instrument known as the United States Department of Defense Form 93, Record of Emergency Data, in accordance with P.L , Section 564, 10 U.S.C. Section 1482; (3) The surviving spouse; (4) Any surviving child of the deceased. If a surviving child is less than eighteen years of age and has a legal or natural guardian, such child shall not be disqualified on the basis of the child's age and such child's legal or natural guardian, if any, shall be entitled to serve in the place of the child unless such child's legal or natural guardian was subject to an action in dissolution from the deceased. In such event the person or persons who may serve as next-of-kin shall serve in the order provided in subdivisions (5) to (9) of this subsection; (5) (a) Any surviving parent of the deceased; or (b) If the deceased is a minor, a surviving parent who has custody of the minor; or (c) If the deceased is a minor and the deceased's parents have joint custody, the parent whose residence is the minor child's residence for purposes of mailing and education; (6) Any surviving sibling of the deceased; (7) The next nearest surviving relative of the deceased by consanguinity or affinity; (8) Any person or friend who assumes financial responsibility for the disposition of the deceased's remains if no next-of-kin assumes such responsibility; (9) The county coroner or medical examiner; provided however that such assumption of responsibility shall not make the coroner, medical examiner, the county, or the state financially responsible for the cost of disposition. 3. The next-of-kin of the deceased shall be entitled to control the final disposition of the remains of any dead human being consistent with all applicable laws, including all applicable health codes. 8

9 4. A funeral director or establishment is entitled to rely on and act according to the lawful instructions of any person claiming to be the next-of-kin of the deceased; provided however, in any civil cause of action against a funeral director or establishment licensed pursuant to this chapter for actions taken regarding the funeral arrangements for a deceased person in the director's or establishment's care, the relative fault, if any, of such funeral director or establishment may be reduced if such actions are taken in reliance upon a person's claim to be the deceased person's next-of-kin. 5. Any person who desires to exercise the right of sepulcher and who has knowledge of an individual or individuals with a superior right to control disposition shall notify such individual or individuals prior to making final arrangements. 6. If an individual with a superior claim is personally served with written notice from a person with an inferior claim that such person desires to exercise the right of sepulcher and the individual so served does not object within forty-eight hours of receipt, such individual shall be deemed to have waived such right. An individual with a superior right may also waive such right at any time if such waiver is in writing and dated. 7. If there is more than one person in a class who are equal in priority and the funeral director has no knowledge of any objection by other members of such class, the funeral director or establishment shall be entitled to rely on and act according to the instructions of the first such person in the class to make arrangements; provided that such person assumes responsibility for the costs of disposition and no other person in such class provides written notice of his or her objection. If the funeral director has knowledge that there is more than one person in a class who are equal in priority and who do not agree on the disposition, the decision of the majority of the members of such class shall control the disposition. 8. For purposes of conducting a majority vote under subsection 7 of this section, the funeral director shall allow voting by proxy using a written authorization or instrument. 9

Name of Decedent: Date of Death: Time: Place of Death: Sex: M F Age: DOB: SS:

Name of Decedent: Date of Death: Time: Place of Death: Sex: M F Age: DOB: SS: No. Date AUTHIZATION F CREMATION AND DISPOSITION The State of Ohio requires that this Authorization Form be completed and signed prior to the cremation. Please read it carefully and ask us any questions