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Authorization for Cremation & Disposition The undersigned hereby certify that they are the legal custodian of the herein named individual, having full legal authority to authorize the cremation, processing and disposition of the cremated remains of the individual and hereby request and authorize provider to take possession of and make arrangements for the cremation, processing and disposition of the remains of: _______________________________________ (Name of Individual to be Cremated) Disposition of Cremated Remains: __1. Sea Scattering pursuant to (7117 (c) H&S) __2. Return to family_______________ __3. Special Handling_______________ A. The authorized representative understands that due to the nature of the cremation process any valuable material, including dental gold, will either be destroyed or not be recoverable. Accordingly, the authorized representative represents and warrants to the provider that all body prostheses, dental bridgework, dental filings or personal articles accompanying the remains: (i) have been removed from the remains or (ii) will be destroyed by the cremation process. B. A surgically implanted pacemaker, chemo pump, or prosthetic device in the deceased may create hazardous conditions when the body is placed in the cremation chamber. The undersigned hereby states that the deceased does__ does not__ (please check one) have one of the above devices. In the event the deceased does have one of the above devices, the undersigned hereby authorizes its removal and disposal in a commercial land fill by the crematory's agent.
C. The following statement(s) are required by law and must be included in this form: 1)The human body burns with the casket, container, or other material in the cremation chamber. Some bone fragments are not combustible at the incineration temperature, and, as a result, remain in the cremation chamber. During the cremation, the contents of the chamber may be moved to facilitate the cremation. The chamber is composed of ceramic or other material that disintegrates slightly during each cremation and the product of that disintegration is commingled with cremated remains. Nearly all of the contents of the cremation chamber consisting of cremated remains, disintegrated chamber material, and small amounts of residue from previous cremations are removed together and are crushed, pulverized or ground, to facilitate inurnment or scattering. Some residue remains in the cracks and uneven places in the chamber. Periodically, the residue is removed and scattered at sea. 2)A person having the right to control disposition of cremated remains may remove the remains in a durable container from the place of cremation or interment, pursuant to Sec 7054.6 of the Health and Safety Code. 3)If the cremated remains container cannot accommodate all cremated remains of the deceased, the crematory shall provide a larger cremated remains container at no additional cost, or place the excess in a second container that cannot easily come apart from the first, pursuant to Section 8345 of the Health and Safety Code.
D. The undersigned agrees to pick up the cremated remains of the deceased at our office during normal office hours, unless prior arrangements have been made regarding disposition. Failure to retrieve cremated remains within 30 days from date of death hereby authorizes the crematory to proceed with scattering at sea and the next of kin, or the responsible party, will be responsible for payment for such service.
E. It is the policy of the crematory to dispose of implanted metal devices (pins, plates, artificial joints, etc.) in commercial land fill pursuant to permission to do so by opinion of the Department of Consumer Affairs.
F. The obligation of the crematory shall be limited to the cremation of the remains of the herein named individual and the disposition, if so directed. No warranties are expressed or implied and any damages shall be limited to the refund of all fees paid. Signature of Person Authorizing Cremation and
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