AUTHORIZATION FOR CREMATION, PROCESSING, AND DISPOSITION OF THE REMAINS OF SOCIAL SECURITY NO.

Transcription

1 Barr-price funeral homes And Crematorium 609 Northwood Road, Lexington SC P: (803) F: (803) AUTHORIZATION FOR CREMATION, PROCESSING, AND DISPOSITION OF THE REMAINS OF SOCIAL SECURITY NO. _ The date and time of death of (hereinafter the Deceased ) was on, at (AM or PM), as indicated on the attached attending physician s, medical examiner s or coroner s certificate of death. The undersigned agent of the Deceased certifies that said agent has the full legal authority and right to authorize the cremation, processing, and disposition of the Deceased s remains, and further, said agent certifies that, to the agent s knowledge, there exists no person who possesses a superior priority right and no person of equal priority who disagrees with this authorization. Exercising the authority aforesaid, I, the undersigned, hereby authorize Barr-Price Funeral Home, and Palmetto Cremations (hereinafter Cremation Authority ); said Cremation Authority being specifically authorized to carry out the process of cremation of the Deceased s remains, in accordance with the provisions of Chapter 8 of Title 32, 1976 S.C. Code, as amended, upon receipt of the Deceased s remains. I, as agent of the Deceased, hereby declare that, to the best of my knowledge (Check one): The Deceased s remains DO NOT contain a pacemaker, or any other material or implant that may be hazardous, or cause damage to, the cremation chamber or the person performing the cremation. The Deceased s remains DO contain a pacemaker, or other material or implant, that may be hazardous, or cause damage to, the cremation chamber or the person performing the cremation.** **Please list all Materials/Implants: I, as agent of the Deceased, hereby declare that, to the best of my knowledge: The Deceased DID NOT have an infectious, contagious, or communicable disease or a disease declared by the Department of Health and Environmental Control to be dangerous to the public health. The Deceased DID have an infectious, contagious, or communicable disease declared by the Department of Health and Environmental Control to be dangerous to the public.**

2 **Please list all diseases: The Agent of the Deceased further authorizes and instructs the Cremation Authority to properly dispose of any items, other than the remains of the Deceased, including, but not limited to, body prostheses, dentures, dental bridgework, and dental fillings that are recovered from the cremation chamber. Jewelry and other personal articles that are recovered from the cremation chamber are to be disposed of as follows: THE CREMATION, PROCESSING, AND DISPOSITION OF THE REMAINS OF THE DECEASED, AS AUTHORIZED ABOVE, SHALL BE PERFORMED IN ACCORDANCE WITH ALL GOVERNING LAWS, AS WELL AS THE RULES, REGULATIONS, AND POLICIES OF BARR-PRICE FUNERAL HOME AND/OR PALMETTO CREMATIONS, SUCH AUTHORIZATION BEING SUBJECT TO THE FOLLOWING TERMS AND CONDITIONS: Please read and initial the following: 1. The remains of the Deceased will not be accepted by the Cremation Authority unless the Deceased is in a casket, cremation casket, or an approved alternative container. 2. The Cremation Authority shall separate and remove from the cremation chamber all noncombustible materials, including, but not limited to, hinges, latches, nails, jewelry, and precious metal, and the Cremation Authority shall dispose of such materials as provided by law and/or as instructed herein. 3. Unless specifically authorized by the Deceased s agent(s), the Cremation Authority shall not simultaneously cremate the remains of more than one person in the same cremation chamber. 4. The services of the Cremation Authority are deemed to be fulfilled when the cremated remains of the Deceased are returned to the custody of Barr-Price Funeral Home. 5. Barr-Price Funeral Home is hereby authorized to dispose of the Deceased s remains as follows: 6. If no method of disposition is specified in number 5 above, the cremated remains of the Deceased are to be held by the Cremation Authority for a period of 30 days, unless said remains are picked up or shipped to the agent or Barr-Price Funeral Home before that time. At the end of 30 days, if final disposition arrangements have not been made, the Cremation Authority may return the cremated remains to the agent of the Deceased or the Barr-Price Funeral Home. 7. If, at the end of 60 days, no final disposition arrangements have been made, the Cremation Authority, or the Funeral Establishment in charge of the disposition arrangements, may dispose of

3 the cremated remains in a manner provided by law, and in accordance with Chapter 8 of Title 32, 1976 S.C. Code, as amended. 8. Deceased s agent may revoke this authorization within 12 hours of its execution by providing written notice to Barr-Price Funeral Home who assisted in making these arrangements and the Cremation Authority designated to perform the cremation. By signing this Cremation Authorization Form, I, as agent for the Deceased, agree that Barr-Price Funeral Home (Funeral Establishment) and Palmetto Cremations (Cremation Authority) and its respective agents, employees, and assigns shall be held harmless in regard to any and all loss, damage, liability, or causes of action in connection with the cremation, processing, and disposition of the Deceased s remains. However, said Funeral Establishment and Cremation Authority and its respective agents, employees, and assigns shall not be held harmless for any acts in regard to the cremation, processing, and disposition of the Deceased s remains if said acts are performed in a grossly negligent manner. FURTHER, I, HEREBY, STATE THAT ALL REPRESENTATIONS AND STATEMENTS MADE BY ME ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE; AND, FURTHER, THAT I HAVE READ AND UNDERSTAND THE PROVISIONS CONTAINED IN THIS DOCUMENT AND THE ATTACHED EXPLANATORY INFORMATION IN REGARD TO THE CREMATION PROCESS. Relationship to Deceased: Telephone Number of Agent: Address of Agent: Agent Signature: Agent Identification #: Witnessed this day of, Witness Signature: Time Signed (AM OR PM) Relationship to Deceased: Telephone Number of Agent: Address of Agent: Agent Signature: Agent Identification #: Witnessed this day of, Witness Signature: Time Signed (AM OR PM) AUTHORIZATION FOR CREMATION, PROCESSING, AND DISPOSITION OF THE REMAINS OF

4 FURTHER, I, HEREBY, STATE THAT ALL REPRESENTATIONS AND STATEMENTS MADE BY ME ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE; AND, FURTHER, THAT I HAVE READ AND UNDERSTAND THE PROVISIONS CONTAINED IN THIS DOCUMENT AND THE ATTACHED EXPLANATORY INFORMATION IN REGARD TO THE CREMATION PROCESS. Relationship to Deceased: Telephone Number of Agent: Address of Agent: Agent Signature: Agent Identification #: Witnessed this day of, Witness Signature: Time Signed (AM OR PM) Relationship to Deceased: Telephone Number of Agent: Address of Agent: Agent Signature: Agent Identification #: Witnessed this day of, Witness Signature: Time Signed (AM OR PM) Address of Agent: Agent Signature: Agent Identification #: Witnessed this day of, Witness Signature: Time Signed (AM OR PM)

5 Batesburg-Leesville, South Carolina (803) Lexington, South Carolina (803) Name Age FIRST MIDDLE LAST Date of Death Hour VITAL STATISTICS DECEASED S ADDRESS CITY-STATE-ZIP COUNTY PLACE OF DEATH CITY-STATE-ZIP COUNTY SEX RACE ETHNICITY MARITAL STATUS CITIZEN M F BIRTHPLACE DATE OF BIRTH FATHER S NAME HIS BIRTHPLACE MOTHER S MAIDEN NAME HER BIRTHPLACE OCCUPATION EMPLOYER SOCIAL SECURITY NO. SURVIVING SPOUSE (IF WIFE, GIVE MAIDEN NAME) IF VETERAN, NAME WAR AND BRANCH OF SERVICE RANK AND SERVICE NO. INFORMANT S NAME AND ADDRESS TELEPHONE CERTIFICATE SIGNED BY CAUSE OF DEATH HIGHEST EDUCATION OTHER INFORMATION

6 LENGTH OF TIME LIVING HERE BIOGRAPHICAL INFORMATION COMING FROM RELIGION CHURCH LIST CLUBS, NOTEWORTHY ACHIEVEMENTS, ETC. SURVIVING RELATIVES FATHER MOTHER HUSBAND/WIFE SONS DAUGHTERS BROTHERS

7 SISTERS GRANDCHILDREN (No.) GREAT-GRANDCHILDREN (No.) IDENTIFICATION - Viewing HOLD HARMLESS AGREEMENT The undersigned, being next-of-kin or other legally authorized person making arrangements, having viewed the remains, either at the place of death or the funeral home prior to cremation, hereby identify the same as the remains of. Ample time has been given the undersigned to assure proper identification prior to the execution of this document, and by signing same; the undersigned acknowledges that there is no doubt or question about this identification. The undersigned assumes all liability for mistaken identification or incorrect identification and does hereby agree to indemnify and hold the Barr-Price Funeral Homes and/or Palmetto Cremations, its officers, agents, and employees, harmless from any and all claims, suites, or causes of action, including a reasonable attorneys fee for the defense thereof, brought by any person, firm or corporation, or the personal representative thereof, arising out of the identification and request for cremation and disposition of the remains. I HAVE READ AND UNDERSTAND THE HOLD HARMLESS AGREEMENT FOR IDENTIFICATION BY VIEWING OR WITHOUT VIEWING. Signed Relationship Telephone Number City, State, Zip Code Witness ************************* IDENTIFICATION - Without viewing HOLD HARMLESS AGREEMENT Date The above signed, being next-of-kin or other legally authorized person making arrangements, having declined to make identification through actual viewing of the remains of, hereby agree to indemnify and hold Barr-Price Funeral Home and/or Palmetto Cremations, its officers, agents, and employees, harmless from any and all claims, suites, or causes of action, including a reasonable attorneys fee for the defense thereof, brought by any person, firm or corporation, or the personal representative thereof, arising out of the identification of, or relating to or arising out of such failure to identify, and request for cremation and disposition of the remains. Reason visual identification not performed: Describe alternative methods used to confirm identification:

8 Name of Funeral Home Representative Date Signature

9 AUTHORIZATION TO RECYCLE METAL FROM IMPLANTED DEVICES AND DENTAL APPLIANCES PARTIES: Barr-Price Funeral Home and Palmetto Cremations REPRESENTATIVE: DECEDENT: RELATIONSHIP OF REPRESENTATIVE: The Representative warrants and represents to Barr-Price Funeral Home and Palmetto Cremations that the relationship between the Representative and Decedent is as follows: (check appropriate box) Spouse Next-of-Kin (Closest Living Relative) Personal Representative of the Next-of-Kin with written authorization of Next-of-Kin to act on his or her behalf. Other AUTHORITY OF REPRESENTATIVE: The Representative warrants and represents to Barr-Price Funeral Home and Palmetto Cremations that the Representative is the person or the appointed agent of the person who by law has the paramount right to arrange and direct the disposal of the remains of the Decedent and that no other person(s) has a superior right over the right of the Representative. RECYCLING OF METAL: Following the cremation process, Palmetto Cremations uses all reasonable efforts to remove from the cremated remains all non-combustible materials such as dental bridgework, dental crowns, implanted medical devices, and metal hinges, latches and nails from the cremation container. Typically, this non-combustible material is disposed if as waste. However, in the case of certain metals that may be found in the implanted devices and dental appliances, such as titanium, gold, silver, platinum or palladium, third party companies will recycle these types of metals that are recovered after cremation. With the express permission of the Representative, these metals will be sent to a recycling company. AUTHORIZATION ON DISPOSITION OF METAL: The Representative authorizes Barr-Price Funeral Home and Palmetto Cremations to take the following action: (please place your initials opposite the option you select: Recycle any metal that is eligible for recycling and dispose of the remaining metal with the remainder of the non (Initials) combustible material, OR Do not recycle the metal. Instead, return it with the remainder of the non-combustible material to the Representative. (Initials) SIGNATURE OF REPRESENTATIVE: DATE: 9