People - Aquamation Authorization

Tillwell Aquamation Authorization Form
Deceased Information
Name*

First NameMiddle NameLast Name
Last Residence*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age*
Place of Death (city/province)*
Legal Representative Information
I, (Legal Representative's Full Name)*

First NameMiddle NameLast Name
Residing at*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
do hereby certify that I have the legal right to authorize aquamation and disposition of the above deceased, as the
(Relationship) of the deceased*
Authorization and Acknowledgment

I accept responsibility for this authorization and absolve Tillwell of any liability on account of said authorization, aquamation, and subsequent disposition.

Medical Implants and Devices

I understand and acknowledge that:
1. During the aquamation process, any medical implants (such as pacemakers, defibrillators, artificial joints, surgical screws, plates, or mesh) will naturally separate from the body
2. These items will be recovered after the process and can be:
  - Safely recycled by Tillwell in accordance with environmental regulations
  - Returned to the family upon request
wish to have medical implants returned after the processauthorize Tillwell to recycle the medical implants
Personal Effects

I understand that Tillwell takes no responsibility for personal effects accompanying the body of the deceased unless specifically listed and acknowledged below:
Personal effects present
Declaration

By signing below, I acknowledge that I have read and understood this authorization form in its entirety. I certify that I have the legal right to authorize this aquamation and that the information provided is true and correct to the best of my knowledge.
Executor/ Next of kinTillwell Agent
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Executor / Next of Kin Email*
example@example.com
Should be Empty:

Tillwell Aquamation Authorization Form

Deceased Information

Legal Representative Information

Authorization and Acknowledgment

Medical Implants and Devices

Personal Effects

Declaration