Cremation Authorization Package

Deceased Information Sheet

R. Bernard Funeral Services
Deceased Full Name

First Name Middle Name Last Name
Date of Birth
Date of Death
Gender
Age
Social Security Number
Birthplace

Street Address

Street Address Line 2

City State

Zip Code
How many days was deceased in hospital?
Doctor's Name
Occupation
Kind of Business
Place of Death
Time of Death (AM / PM)
Place of Burial
Cremation
Marital Status
Level of Education
Surviving Spouse

First Name Maiden Last Name
U.S. Army Forces
Deceased Father's Name

First Name Last Name
Deceased Mother's Name

First Name Maiden Last Name
Deceased Address

Street Address

Street Address Line 2

City State

Zip Code
Family Member's Name (informant)

First Name Last Name
Relationship to deceased blanks
Family Member's Address (informant)

Street Address

Street Address Line 2

City State

Zip Code
Family Member's Phone Number (informant)
Please enter a valid phone number.
Family Member's Email (informant)
example@example.com

Authorization For Cremation And Disposition Of Human Rights:

R. Bernard Funeral Services
R. Bernard Funeral Services (Name of Crematory)

2764 Lamar Ave. (Address Of Crematory)

Memphis, Tennessee 38114

Phone: (901) 440-0100 Fax: (901) 201-5836
I(We), the undersigned (Authorizing Agent(s)), hereby authorize R. Bernard Funeral Services, Memphis, Tennessee (Funeral home) and R. Bernard Funeral Services (crematory)to cremate the human remains of the decedent names below in accordance with provisions set forth in the document and all applicable laws, rules and regulations. I (We) have identified the human remains that were delivered to the funeral home as the decedent and have authorized the funeral home to deliver the decedent to the crematory.
Identification
Name of Deceased:First Name Last Name
Sex Age Date of Death Pace of Death
Preneed Cremation Arrangement
Did the decedent arrange for his or her own cremation, on a preened basis?
Did the decedent leave a will with written instructions to be cremated?
Did the decedent leave oral instructions to be cremated?
If yes, with whom? blanks
Did the decedent arrange for final disposition of the cremated remains?
If yes, please describe: blanks
Pacemakers, Prosthesis, Silicon and Radioactive Implants
Mechanical, radioactive devices or implants may create a hazardous condition when placed in the cremation chamber. Please list all the existing devices or implants that should be removed prior to cremation.
Witnessing
Are there any people who wish to witness the casket or container being placed in the Cremation chamber?

None

Final Disposition
After cremation, the Crematory will arrange for the disposition of the cremated remains as folows, and the Authorizing Agent(s) hereby authorizes the Crematory to release, deliver, transport, or ship the cremated remains as specified. Choose one of the following:
1.) Deliver the cremated remains to cemetery, where arrangements have already been made for the cremated remains to be:

No
2.) Deliver or release the cremated remains to the following designated person:

No
3.) Deliver the cremated remains to the U.S Postal Service, where they will be mailed by the acceptable method to:

No
4.) Deliver cremated remains to the Funeral Home?

Yes, R. Bernard Funeral Services
5.) Other

No
Authority of Authorizing Agents
I (We) hereby certify that the Decedent left the following surviving heirs:
Spouse:
Name of Spouse:
Children:
How many children?
Name of children?
Parents:
How many parents?
Name of parents?
Siblings:
How many siblings?
Name of Siblings?
Other
Name / Relationship to decedent?
If the legal next of kin or if all persons of the same degree of kinship are not signing below, a written explanation must be completed by the person(s) signing below as Authorizing Agent(s). If the Authorizing Agent has a valid Durable Power of attorney for Healthcare in accordance with Tennessee Code Ann. Section 62-5-703 and 34-6-204, please attach a copy to this form.
File Upload

Cancel of
I (We) hereby certify that I am the closest living next of kin of the decedent, or that I otherwise serve in the capacity of blanks to the decedent, that I have charge of the remains of the Decedent and possess full legal authority and power to execute the authorization for and to arrange for the cremation and disposition of the cremated remains of the decedent. I am aware of no objection to this cremation by any spouse, child, parent, or sibling specified.
Signature

Clear

Limitation Of Liability
To the extent provided by Tennessee Code Annoted Sections 62-5-107 and 62-5-511, I (we) agree to indemnify and hold the Cremamtory harmless from any loss, damages, or liability concerning the failure to correctly identify the remains of the decedent, disclose the presence of any implanted mechanical or radioactive devices, or final disposition of the remains of the decedent.
Signature of Authorizing Agent
This is a legal document. Cremation is irreversible and final.

Read all portions of this document carefully before signing.

By executing this Cremation Authorization Form, as Authorizing Agent(s), I (we) warrent that all representations and statements contained in this form are correct and true, and that I (we) have read and understand all the provisions contained in this form.
1.) Name / Relationship / Date / Phone Number / Address
1.) Signature

Clear
2.) Name / Relationship / Date / Phone Number / Address
2.) Signature

Clear
3.) Name / Relationship / Date / Phone Number / Address
3.) Signature

Clear
4.) Name / Relationship / Date / Phone Number / Address
4.) Signature

Clear
5026 TN

(License #) (State) (Signature of Funeral Director as witness) (Date)
Representation Of Funeral Director
I warrent, to the best of my knowledge, that I have reviwed this form with the Authorizing Agent(s), that no member of the funeral home has any knowedge or information that would lead us to believe that any of the answers provided by the Authorizing Agent(s) are incorrect, that the human remains delivered to the Crematory and represented as the human remains of the decedent is the decedent, that our funeral home obtained all necessary permits authorizing the cremation and those permits are attached, and the representations concerning a pacemaker or other implants are true.
Signature

Clear
Date

Month Day Year
Date

R. BERNARD FUNERAL SERVICES OWNS AND OPERATES ITS OWN CREMATORY
Although R. Bernard Funeral Services owns and operates it's own on-site crematory, we have state and federal guidelines that we have to comply with.

STEP 1: The next of kin of the deceased (ex: spouse, parent, etc.) has to complete an Authorization For Cremation and Disposition of Remains Form. ALL parties must sign the form before the cremation process can begin (EX. if the deceased have five children, ALL children must sign the form; EX. if the deceased has a spouse and is not legally divorced, the spouse must STILL sign before the cremation process can begin.)

STEP 2: The pronouncing physician has to complete and sign a form stating the cause of death, license number, and doctor's name. The doctor then has to send the form to the Forensic's office for approval of the cremation process. R. Bernard Funeral Services has NO CONTROL over the time frame that the physician will sign this form.

Step 3: Medical Examiner's office will review the form from the doctor (if approved) and will send the form to the Health Department for approval.

Step 4: The Health Department will review the form from the Medical Examiner's office. Once approved by the Heath Department, they will contact R. Bernard Funeral Services and give us permission to cremate your loved one.
Signature

Clear

AUTHORIZATION / Pick-Up Only / Direct Cremation

R. Bernard Funeral Services
I hereby design the above-named funeral establishment to take charge of funeral arrangements for blanks , and I authorize the release and removal of the remains to said funeral establishment for the purpose of embalming. I represent that I am the next of kin, or am acting as an authorized agent for the next of kin.

Signature
Signature to deceased
Date
Should be Empty:

Deceased Information Sheet

Authorization For Cremation And Disposition Of Human Rights:

Identification

Preneed Cremation Arrangement

Pacemakers, Prosthesis, Silicon and Radioactive Implants

Witnessing

Final Disposition

Authority of Authorizing Agents

Limitation Of Liability

Signature of Authorizing Agent

Representation Of Funeral Director

R. BERNARD FUNERAL SERVICES OWNS AND OPERATES ITS OWN CREMATORY

AUTHORIZATION / Pick-Up Only / Direct Cremation