Authorization for Cremation and Disposition

I/We the undersigned, verify, warrant and represent that I/we have the full legal right and authority to authorize the cremation, processing and disposition of the remains of:(hereinafter referred to as “Deceased”)

I/We hereby request and authorize Rogers Family Mortuary, Inc. (hereinafter referred to as “Funeral Home”) and/or their agent to take possession of and make arrangements for the cremation of the remains of the Deceased at Rogers Family Mortuary Crematory and/or their agent. I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custody of the authorized Funeral Home. I/We understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the Deceased are returned to the possession and custody of the Funeral Home. I/We  authorize the Funeral Home to arrange for the disposition of the cremated remains of the Deceased as follows:

There will be a viewing or service held prior to cremation (circle one) Yes No If So, Date and Time NOTE: by circling “Yes” for a visitation or service, I/we hereby authorize the funeral home to prepare the deceased for viewing by utilizing any professional standards and/or practices deemed necessary by the funeral home. Special Instructions:

Ship via U.S. Postal Service by Priority Mail Express to:

The cremation, processing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all governing laws (CRS 12-54-102), rules, regulations, and policies of Rogers Family Mortuary Crematory, and under the following terms and conditions:

1. The Deceased named above has been identified by the authorizing agent/s as the deceased person to be cremated. The Deceased must be received by the Crematory in a combustible, leak resistant, rigid container or casket providing a complete covering for the Deceased, and providing protection for the health & safety of the crematory operator. The Crematory does not accept metal caskets for cremation.

2. Mechanical or radioactive devices, or silicon implants within the Deceased’s body may create a hazardous condition when placed in the Crematory. I/We hereby authorize the Funeral Home, its agents and/or it’s employees to remove any such device(s) from the remains prior to cremation and dispose of at its discretion. CONTAIN ANY TYPE OF IMPLANTED DEVICE.

3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will be totally and irreversibly consumed by prolonged exposure to intense heat and direct flame.

4. Certain items including, but not limited to, body prostheses, dentures, dental bridgework, dental fillings, jewelry and other personal articles accompanying the remains of the Deceased may be destroyed during the cremation process. I/We further authorize that if any items, other than the cremated remains of the Deceased, may be separated from the cremated remains of the Deceased and disposed of by the Crematory.

5. Following cremation, the cremated remains of the Deceased, consisting primarily of bone fragments, will be processed into small particles for placement into an urn.

6. In the event the urn or container is insufficient to accommodate all of the cremated remains of the Deceased, any excess cremated remains will be placed in a secondary container and returned to the Funeral Home with the primary urn.

7. I/We understand and acknowledge, that even with the exercise of reasonable care and use of the Crematory’s best efforts, it is not possible to recover each residual particle of the cremated remains of the Deceased, and that some particles may inadvertently become commingled with particles of other cremated remains remaining in the cremation chamber and/or other devices utilized to process the cremated remains. I/We hereby authorize the Crematory to dispose of any such residual particles in any lawful manner it deems appropriate.

8. I/We agree to indemnify, release and hold Rogers Family Mortuary Crematory, the Funeral Home, their affiliates, agents, employees and assigns, harmless from any and all loss, damages, liability or causes of action (including attorney’s fees and expenses of litigation) in connection with the cremation and disposition of the cremated remains of the Deceased, as authorized herein or my/our failure to correctly identify the remains of the Deceased, disclose the presence of any implanted silicon, mechanical, or radioactive device, or take possession of, or make permanent arrangements for the disposition of such cremated remains. In the event the Crematory and/or Funeral Home is brought into any litigation acting upon this authorization, the undersigned agrees to pay all legal fees, costs and expenses incurred.

9. Except as set forth in this authorization, no warranties, expressed or implied, are made by the Funeral Home, Crematory or any of their respective affiliates, agents, or employees.

10. I/We understand that this document does not contain a complete and detailed description of every aspect of the cremation process.

11. A funeral establishment, funeral director, or mortuary science practitioner may dispose of cremated remains at the expense of the person with the right of final disposition one hundred eighty days after cremation if the person was given clear prior notice and a reasonable opportunity to collect the remains, the exact location of the final disposition and the costs associated with the final disposition are recorded, and the recovery of the remains is possible. Recovery of costs is limited to a reasonable amount of the costs actually expended by the funeral establishment, funeral director, or mortuary science practitioner. If cremated remains are not claimed by the person with the right of final disposition within three years after cremation, a funeral establishment, funeral director, or mortuary science practitioner may dispose of the remains in an unrecoverable manner by placing the remains in an ossuary or by scattering the remains in a dedicated cemetery, scattering garden, or consecrated ground used exclusively for these purposes.

We require that the legal and equal next of kin (spouse, then children, then parents, then siblings, etc.) sign this document according to CRS 15-19-106 unless a court order or other legal document direct otherwise. For example, the majority surviving children must consent when there is no surviving spouse. It is the responsibility of the legal survivors, not Rogers Family Mortuary Crematory, to make sure all required signatures are provided. It may be necessary to fax this document to another legal survivor upon the direction of the person(s) arranging cremation. We require that this form be signed, dated, and include the individual’s relationship to the Deceased, address and telephone number. If the legal next of kin or if all persons of the same degree of kinship are not signing, a written explanation must be completed by the person(s) signing below as authorizing agent(s). Separate authorization(s), if necessary, shall be attached to, and considered part of this form. I/We, the undersigned, hereby certify that I/we are the closest living next of kin of the Deceased and that I/we are related to the deceased as his/her:

In addition, I/we have made a reasonable inquiry, and are aware of no objection to the cremation of the deceased by anyone signing of equal authority.I/We further warrant that all representations and statements made herein are true and correct, and that I/we have read and understand the provisions contained in this document.

Witness & Title/Relationship