Authorization for Cremation

Everglades Crematorium

153332 NW 7th Avenue

Miami, Florida 33169

(305) 688-2030

Pacemaker:

Yes No

The undersigned hereby requests and authorizes, in accordance with and subject to your rules and regulations as well as those of the State of Florida, to cremate the remains and

(Type of container)

containing the remains of

(Name in Full)

who died at

(city and State)

, on

(Day) (Month) (Year)

at

(Hour)

and certifies and represents that I/we have the right to make such authorization and am related to the deceased as

(Relationship)

Cremation will take place on or before

Signature of Person Authorizing the Cremation

I/We also request you to make the following disposition of the cremated remains:

REGISTERED U.S. MAILING INSTRUCTIONS

The undersigned hereby authorizes the crematory to deliver the cremains via REGISTERED U.S. MAIL and agrees to assume all liability for any damages that may arise from any cause growing out of said delivery and to indemnify and hold harmless the crematory and funeral director or their employees from any and all claims related to said shipment. The undersigned also agrees to pay for such delivery in the amount of $

I/We agree to hold you, your servants, and employees blameless, from any and all liability whatsoever, also for any loss or damage to said cremated remains, occasioned by an act of God, a common enemy, theft, strikes, riots, vandals, order of Military or Civil Authority, and for any other act beyond our control.

If no final disposition instructions are given to the crematory or funeral home, the cremated remains will be held for 120 days from date of death and then disposed of in a dignified manner.

Heart pacemakers can be dangerous when placed in a cremation chamber and shall be removed prior to the cremation process. If the crematory does not receive proper notice, the family and/or undersigned shall be responsible for any damage resulting and the crematory will not be responsible or accept any liability under those circumstances.

I/We affirm that the above statement is true.

SIGNED

Clear

ADDRESS

WITNESS

ADDRESS

(Funeral Director's Signature)

Signed and sworn to before me this

day of

(Notary Public Signature)

Date of disposition

By

Cremated remains received by

(Relationship)

on

(Relationship)

The named deceased was received by the

(Name of Crematory)

in

(Type container)

approved by the Rules and Regulations of the State Board of Funeral Directors and Embalmers for Florida governing Crematories and that the 48hour period since death had elapsed before said deceased was cremated on

(date)

Signed

Clear

RULES APPLICABLE TO CREMATORIES:

It shall be unlawful for any person, firm or corporation to cremate any dead human body prior to the expiration of forty-eight(48) hours after the death of such human body. (Sec. 872.02(I), F.S.)

A dead human body may be held any place or in transit over twenty-four (24) hours after death or pending final disposition only if the body is maintained under refrigeration at a temperature of 40°F or below; embalmed in a manner approved by the Board of Funeral Director and Embalmers in accordance with provisions of Chapter 497 F.S.; or otherwise preserved. (Division of Health Rules - Gen. Authority Sec. 381.03(l)g(ll), F.S.).

Crematory or cinerator facilities are permitted only to require a container in the form of a cardboard container of suitable strength or a wooden box or casket chosen for cremation or calcination to take place. In such cases where the deceased died from a contagious disease, an air-tight container will be required to stop fluid leakage and offensive odors and to reduce the possible further spread of the contagion. (Ch. 21-J-9.03(g)-FD&E Rules)