Authorization For Cremation And Disposition Form

The State of Ohio requires that this Authorization Form be completed and signed prior to cremation. Please read it carefully and ask us any

questions you may have. Cremation is an irreversible and final process. It is important that you understand the cremation process that is

described in Section 9 of this Authorization Form prior to signing it. We want you to fully understand the information provided in this

Authorization form, so we will be pleased to answer any questions about the cremation process or the other information in this Form.

THE AUTHORIZATION IS NOT A CONTRACT FOR CREMATION SERVICES. A SEPARATE CONTRACT OR CONTRACTS

WILL BE REQUIRED TO PURCHASE THE SERVICES OF THE FUNERAL HOME AND/OR CREMATORY

1. Identification of the decedent

OR

OR

OR

2.  Funeral Home and Crematory

The Authorizing Agent authorizes the Funeral Home and Crematory set forth below to carry out the directions

and instructions of the Authorizing Agent contained in this Authorization Form.

3. Identification of Authorizing Agent

4. Authority of Authorizing Agent

As Authorizing Agent, I represent that I have the right to authorize the cremation of the Decedent’s remains and

I am initialing one of the following three statements accordingly:

OR

OR

5. Pacemakers, Implants, and Prostheses

Pacemakers, radioactive, silicon or other implants, mechanical devices or prostheses may create a hazardous

condition when placed in the cremation chamber and subjected to heat. As Authorizing Agent, I have listed all

the devices (including mechanical, prosthetic, implants, or materials), which may have been implanted in or

attached to the Decedent.

Please intial one of the following statements:

OR

6. Casket or Alternative Container

The remains are to be cremated in a combustible casket or alternative container that is capable of being

completely closed, is resistant to leakage or spillage, is sufficiently rigid to be handled easily, and provides

protection for the health and safety of Crematory and Funeral Home personnel. The Crematory is authorized

to inspect the casket or alternative container, including opening it if necessary. In the event that the casket

or container does not meet the above requirements, the Crematory will notify the Authorizing Agent. Many caskets that are comprised primarily of combustible material also contain some exterior parts (decorative handles or rails) that are not combustible and

that may cause damage to the cremation equipment. As Authorizing Agent, I authorize the crematory, in it’s discretion, to remove and discard the

non-combustible materials. I understand that some crematories will not accept metal or fiberglass caskets. I further understand that the casket or

alternative container will be consumed as part of the cremation process. Lake Erie Cremation & Funeral Services will not accept any cremation containers

comprised of metal, fiberglass or solid hardwood.

7. Multiple Cremations

Under Ohio law, the remains of more than one decedent may not be simultaneously cremated in the same

cremation chamber unless the decedents to be cremated were related or were, any time during the one-year

preceding their deaths cohabiting. Unless authorized below, the Decedent’s remains shall be individually

cremated. If you desire a multiple cremation, initial below.

8. Witnesses

Witnessing a cremation can be an emotional experience. Witnesses are assuming the risks involved and fully

release the Funeral Home and Crematory from any liability. To the extent permitted by the Crematory, the

persons listed below are authorized to be present at the cremation room prior to and during the cremation of the

Decedent’s remains. If you desire to witness you must initial below

OR

9. The Cremation Process

The cremation of the Decedent’s remains may take place before or after ceremonies to memorialize the Decedent.

Cremation is carried out by placing the Decedent’s remains in the casket or alternative container, which is then

placed into a cremation chamber or retort where they are subjected to intense heat and flame. All cremations are

performed individually unless noted otherwise in Section 7 above. During the cremation process, it may be necessary to open the cremation chamber and reposition the remains of the Decedent in order to facilitate a complete

and thorough cremation. Through the

use of suitable fuel, the incineration of the container and its contents is accomplished and all substances are consumed or driven off, except bone fragments

(calcium compounds) and metal (including dental gold and silver and other non-human materials) as the temperature is not sufficient to consume them.

Due to the nature of the cremation process, any personal possessions or valuable materials, such as dental gold or jewelry (as well as any body prostheses

or dental bridgework) that are left with the remains and not removed from the casket or container prior to cremation may be destroyed or if not destroyed,

will be disposed of by the Crematory. The Authorizing Agent understands that arrangements must be made with the Funeral Home to remove any such

possessions or valuables prior to the time that the remains of the Decedent are transported to the Crematory.

Following a cooling period, the cremated remains, which will normally weigh several pounds in the case of an average-size adult, are then swept or raked

from the cremation chamber. Although the Crematory will take reasonable efforts to remove all of the cremated remains from the cremation chamber, it is

impossible to remove all of them, as some dust and other residue from the process will be left behind. In addition, while every effort will be made to avoid

commingling, inadvertent and incidental commingling of minute particles of cremated remains from the residues of previous cremations is a possibility,

and the Authorizing Agent understands and accepts this fact.

After the cremated remains are removed from the cremation chamber, all non- combustible material (insofar as possible) such as dental bridgework

and hinges, latches, and nails from the container will be separated and removed from the human bone fragments by visible or magnetic selection. The

Crematory is authorized to dispose of these materials with similar materials from other cremations in a non-recoverable manner, so that only human bone

fragments will remain.

When the cremated remains are removed from the cremation chamber, the skeletal remains often will contain recognizable bone fragments. Unless

otherwise specified, after the bone fragments have been separated from the other material, they will be mechanically pulverized. The process of crushing or

grinding may cause incidental commingling of the remains with the residue from the processing of previously cremated remains. These granulated

particles of unidentifiable dimensions, which are virtually unrecognizable as human remains, will then be placed into a designated container.

10. Authorization to cremate, process and Pulverize

11. Urn or Temporary Container Use

After the cremated remains have been processed, they will be placed in the urn listed below or, if an urn is not

provided to the Crematory, in a temporary container provided by the Crematory. The Authorizing Agent

acknowledges that it is impossible to recover all of the dust and residue from the cremation and processing.

In the case of an adult, it is recommended that the urn or temporary container be a minimum size of 200 cubic inches. In the event the urn or temporary

container is insufficient to accommodate all of the cremated remains, the excess will be placed by the Crematory in a secondary container. This secondary

container will be kept with the urn or the temporary container and handled according to the final disposition instructions set forth in Section 12 below,

provided, however, that the secondary container may not be designed for shipping. All urns or containers provided to the Funeral Home or Crematory

must be appropriate for shipping. The Authorizing Agent directs the Crematory to use the specified urn or container listed in #11.

12. Final Disposition

Following the cremation, the Authorizing Agent directs the Crematory and/or Funeral

Home to undertake the actions set forth below to arrange the final disposition of the cremated remains of the Decedent. If the cremated remains are shipped at any time, the Authorizing Agent directs that the Crematory or Funeral Home utilize overnight express with a return receipt or a shipping service that uses an internal system for tracking the location of the cremated remains during shipment and requires a signed receipt of the person taking delivery of the cremated remains. The Authorizing Agent understands that if no arrangements for the final disposition, release or shipment of the cremated remains are made in this Authorization, the Crematory and/or the Funeral Home shall hold the cremated remains for thirty (30) days after cremation. If during that (30) day period the cremated remains are not retrieved by the person designated above to receive them or by the Authorizing Agent, or if arrangements for

their final disposition are not made, then the Crematory or Funeral Home may return the cremated remains to the Authorizing Agent at the address listed in Section #3. In the alternative, if no arrangements for the final disposition of the cremated remains have been made within sixty (60) days after the cremation and if the Authorizing Agent has not taken delivery of or caused the delivery of the cremated remains, or in the event the arrangements of the final disposition have not been carried out within the sixty (60) day period because of the inaction of a party other than the Crematory or Funeral Home, then the Crematory or Funeral Home may dispose of the cremated remains in a grave, crypt or niche. The Authorizing Agent shall be liable for the cost of such final disposition in a grave, crypt or niche and shall reimburse the Funeral Home immediately upon receipt of an invoice.

OR

13. Personal Property

All personal property and effects delivered with the remains of the Decedent to the Crematory, including jewelry, clothes, hair pieces, dental bridgework, eyeglasses, and shoes will be destroyed in the cremation process or otherwise discarded by the Crematory, in its sole discretion, unless specific instructions for delivery to the Authorizing Agent are given below.

14. Visitation and funeral ceremonies

15. Time Of Cremation

As indicated in the completed Non-Provisional Death Certificate, the cremation of the Decedent’s remains cannot take place until 24 hours have elapsed from the time of death. If the remains are not embalmed and if the cremation is not to occur within eight (8) hours of the delivery of the remains to the Crematory, the Crematory will place the remains in a refrigerated facility for which there will be a daily charge (after 3 days)

Decedent’s remains:

Initials

OR

16. Certification and Indemnification 

The Authorizing Agent acknowledges that the Funeral Home and Crematory are relying

upon the representations being made by the Authorizing Agent in this authorization. The Authorizing Agent certifies that all of the information and statements contained in the Authorization are accurate and no omissions of any material fact have been made. The Authorizing Agent agrees to indemnify and hold harmless the Funeral Home and the Crematory, their officers, directors, employees and agents from any and all claims, demands, actions, causes of action or suits of any kind or nature whatsoever, including, but not limited to, any legal fees arising out of or resulting from the Funeral Home’s and Crematory’s reliance on or performance consistent with the directions, statements, representations and agreements contained in the Authorization.

CERTIFICATION BY FUNERAL HOME UPON TRANSFER OF DECEDENT’S REMAINS TO THE CREMATORY