I(we) the undersigned (the "Authorizing Agent(s)" hereby authorize and request Brandywine Valley Cremation Care (hereinafter known as B.V.C.C.), in accordance with and subject to its rules and regulations, and any state and local laws and regulations to cremate the human remains of (the "decedent"), and certifies that he or she has the right to make such authorization. I understand that all jewelry and valuable material, including dental gold, if not removed from the deceased prior to cremation, if not destroyed by the cremation process, will be disposed of by B.V.C.C.
Name of "DECEDENT" *
PACEMAKERS, PROSTHESES, SILICON AND RADIOACTIVE IMPLANTS ALL PACEMAKERS AND RADIOACTIVE IMPLANTS/SEEDS MAY BE DANGEROUS WHEN PLACED IN A CREMATION CHAMBER AND MUST BE REMOVED PRIOR TO DELIVERING THE DECEDENT TO B.V.C.C.
The decedent's remains DO NOT contain a pacemaker, radioactive implant or any other device that could be harmful to the crematory. THEY ARE SAFE TO CREMATE.
The decedent's remains DO contain a pacemaker, or radioactive implant. By my initials below I hereby grant B.V.C.C. authority to surgically remove or, in the case of radioactive implants, cause to be removed by a competent medical provider. I hereby agree to indemnify B.V.C.C. for all charges thus incurred.
The following list contains all existing devices (including all mechanical, radioactive implants and prosthetic devices) which are implanted in or attached to the decedent that should be removed prior to cremation:
After the cremation has taken place, the cremated remains have been processed and the processed cremated remains placed in the designated receptacle, B.V.C.C. will arrange for the disposition of the cremated remains as follows, and the Authorizing Agent(s) here authorize B.V.C.C. to release, deliver, transport, or ship the cremated remains as specified.
Deliver the cremated remains (enter further information below) Hold the cremated remains at Brandywine Valley Cremation Care. (If the facility is to retain custody of the cremated remains for longer than 30 days, Brandywine Valley Cremation Care requires the use of a permanent, non-combustible container.) Release cremated remains to B.V.C.C. for burial at sea. Release cremated remains to B.V.C.C. to consign to earth. Deliver the cremated remains to the U.S. Postal Service for shipment by Registered Return Receipt mail (enter further information below)
Deliver to: Deliver by (date and time):
Address for shipment: Other instructions:
If shipment by Registered Return Receipt mail is selected, then I(we) agree to assume aIl liability that may arise from such shipment; and to indemnify and hold B.V.C.C. harmless from any and aIl claims that may arise from such shipment.
Initials of authorizing agent
I(we), the undersigned, hereby certify that I am the closest living next of kin of the decedent and that I am related to the decedent as his/her [relation], or that I otherwise serve (served) in the capacity of [capacity] to the decedent, that I have charge of the remains of the decedent and as such possess full legal authority and power, according the laws of the state of [state], to execute the authorization form and to arrange for the cremation and disposition of the cremated remains of the decedent. In addition, I am aware of no objection to this cremation by any spouse, child, parent, or sibling.
Relation *
Capacity *
State *
As the Authorizing Agent(s), I(we) hereby agree to indemnify, defend, and hold harmless B.V.C.C., its officers, agents and employees, of and from any and all claims, demands, 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 result of, based upon or connected with this authorization, including the failure to properly identify the decedent or the human remains transmitted to B.V.C.C., the processing, shipping and final disposition of the decedent'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 harmful 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 B.V.C.C., its officers, agents, or employees, pursuant to this authorization, excepting only acts of willful negligence.
THIS IS A LEGAL DOCUMENT, IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.
By executing this Cremation Authorization Form, as Authorizing Agent(s), the undersigned warrant that all representations and statements contained on this form are true and correct, that these statements were made to induce B.V.C.C.to cremate the human remains of the decedent, and that the undersigned have read and understand the provisions contained on this form and the attached document entitled "B.V.C.C. POLICIES, PROCEDURES AND REQUIREMENTS," and hereby authorize B.V.C.C. to perform the cremation of the decedent in accordance with that document.
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