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Worden, Eloise TrottAPR-04-93 TUE 01:28 PM MOSS FEASTER BELCHER RD 913 362 2073 _- CONTRACT a- 0005 t- CIIAPEL ABl?t- !1477 2n, DOD: 'a - Fk''f - 1991 TOO: 9'. oo. F. n'r. DOC: 44? AUTHORIZATION FOR CREMATION AND DISPOSITION NOTICE: TIDS 13 A LtU.41, OOCUNIENT, tT CONTAINS IMPORTANT rROn9SIONS CONCERNING CREMATION. CREMATION is iRRF,VERSI OLE AND FINAL READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. t/nvr, the undtnlgn<d, c<nlfy, w.mN ..it represent Ih11 11w1 have the ?ull?e al rtght d?uthoMy M authorize Ile cnmatlon, precrsaing and disposition of the rcmei.r of l o t S C N ^ ^....e (hcrelmftcr "fee"d to as the ^Oeceesed"). 1/W. hereby "Quest and authorize Mori • F rA571?rz _ (h-Oreifl" refe?rredr to .9 the "Fune"I Homu^) to take possession of and make soon ?emeNS for tits cremation 014h. "maitreof the Dcecued at ? 1 -1 .»wn (hereinafter referred to as the Crematory^). I/We authorize the Crematory in "turn tits cremated remalns of the Deceased to tit. possession and custody of the Funeral Home. I/We understand that the services and oblIzAtlonz of the Crematory shall be tulfrlled when the cremated --At-- of the Deceased are "turned to the possession and custody of the Funeral Home. I/Wk hereby authorize the Funeral floors, to srtangs foe the dispo.ltion of the cremated re in ai no of the Deceased as follows, Is •pectat h•odling n t.lred7 WY., O No fNecrib Pt <-' ACr" 1 ns'S f N L(Aio LYescription ofurn or eonldnerldeged: Sp4N Cot•e`d,c Suitable for shipping, ITYlu, ON. U Deliver to t-Et d N.4 r.7« C m "r F r. er ,ti U -0t. s Cemetery r,nsmy O Reisut to family »x ,, ro ... w . •ew„• O Scattering at sea by Funeral Home or Funeral Home's agent O Ship H¦ To: Name Address ? O1hcr The cremstion, praeseing read dl,posttfon of the rondosor the Decessed aulhoriNd herein shall be performed en accordance with ail governing laws, the rules, regulations and policlea of the Crematoryand Funtral Home, and ilia following terms and conditions: 1. 'rho remains ofthe Deceased will not be accepted for cremation unless received by the Crematory In a combustible, leak "xlslant, rigid CremAtion conlsiner. The Crematory fa authorized to remove and Ciliate or bandies, ornament. and an other nen- cnmhu'tlWo teems atlsched to the cramslion container prior to cremation. In Ilia event the remains or the Decrasedyart rtcelved by the Crematory In A'cafkst or other container constructed of metal 0"rgtass, or other noncombustible materials. Ifwe authorize tite remains or the Deceased to be 'removed prior to cremation Znd placed In a combustible cremation container. I/We further ..(hest,, the Funeral Hoare or Cremalory to make disposition of any such noncombustible casket In any lawful manner It deems appropriate. 2. lle<hanksl or ndlo•cliv. devices Implanted In tits remains of the Deceased (such as paesmakere, etc.) may create a harard wit" placed In the c"mati0n clam"'. The Crematory will not cremate any human remains which contain any lypa of Implanted coach. nitat or ndioeodve devic,. In the event the remains of ilia Deceased contain much is d-Ic,. 1/ws hereby authorize the Funeral Iloms, Its agents end employee., to remove any such mechanical devices floor the remains of the Deceased prior to erenutlon, and dispose Of each I1. me at lip discretion. 1/N'E HERBRT CERTIrY THAT THE REMAINS O THE DECEASED OO D DO NOTIZ CONFAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. picas. Initial one. IJetad below are all Implanted mechanical and radioactive devices which the Funeral Home Is authorized to remove from the remains of the Deceased prior to cremation, and dispose of as Indicattdo D..r4W. 71^p,r,wA e.nrr `? nlyw.tb, •-' It no instruction for d4flo.Illon 1s given, such Iteuu may be disposed of at Ole discretion crib* Funeral Home. 3. The c"motion container containing the remains of the Deceased will be placed In the cnmHion chamber and will be totally and irreversibly t estmy"d by prolonged exposure to Intense heat and direct flame. CAW authorize tits Crematory to open the cremation chamber during the enroadon process and reposition the remains of the Deceased in order to facilitate a complete and thorough cremation. 4, Certain Items, including, but not limiud to bodyy• pratheacs, dcnfures, dental bridgework, denlai 1UHnpr? Jewtley, slid other personal ankles accompanying (he remains of the Deceased, mey be destroyed during the crtmotlon pprocess. l/Hre further authorize that if any Items, other than the cremated remains or the Deceased, Are recovered from the cremation chamber, [hey may be tapented from the cremated remains of the Deceased and disposed of by the Crematory. 5. We hereby authorize the Crematory to separate and remove from the cremation chamber all noncombustible material., including, but not limited to, hinges, Islehos, nails, jewelry and p"clous metals, and to dispose of such materials. 6. Following eremetion, the cremated remains of the Deceased, consisting pri narily of bone fragments, will be mechanically pulverized to an unldenllpsble consistency prior to placement In an urn or other container. 7. Unless an um or container suitable for shipment is purchased, the Crematory will place the cremated remains of the Deceased In ¦ container which is not designed for any type of thiptnent. It. In the event the urn or container Is Insuff)citnt to oceommodAle all of the crrmated remains of the D.cc.isd. any exeast cremated remains will be placed In A Secondary container and returned to the Funeral Ftoma, logether with the primary urn or container. 9. ]/%Ye undcntand and acknowledge. Choi even with live exercise orret.onable core and the use of the Crematory's hen efforts, 11 is nor possible in recover all porlicirs or the cremated remains of the Deceased, and that scene particles may inadvertently become commingled with panicle, Of Other cremated "mains remaining In the cremation chamber and/or other dr'vlces utilized to proeesv the cremated remains. I/We hereby authorise the Crematory to dispose of any such residual particles In any lawful manner It deems appropriate. 10. Unless 11we Iva epeeine written Inslr.01.ns In tilt. Aulhod-ii.n, the cremation, processing and disposition orthe "mains orthe Deceased will not be performed In mccordsnce with any particular nliglovo or ethnic customs. It. In the event the cremsled remains orthe Deceased remain unclaimed for a period of 3D days, the Funeral Home shall give written notice so me/u, by c.,Ontd en.o at the address es) Indicated "low. VWe agree that In the event the cremated "mains of The Deceased --.in ..claimed, for . period of 110 days Oter the date such writttn notification Is mailed, the Funeral flomr Is authorized end directed to dispose of the unclaimed cremated remains or the Dictated In any lawful manner It may deem A pproprlete. 12. 1/6'c y"e to Indonnify, "less* and hold the Crematory, Funeral Home, their affiliates, agents, empto)- and assigns, hannltss from any and all lose, damages, liability orceusas of action (including attorneys' Res and exilpet roes M IltigAtlon) In connection with d" cr•rnstioa ..it di.poskion of the errmat.J remains or the Deceased. or au Chortled bcmin, or env/our failure O) correctly tit cntirr it,, rematos of the Deceased; disclose the presence of any Implanted mechanical or radioactive devices, ortake possession of. or nuke pcrmaneol arrangements for, the disposition orsuch remains. 13. Except as set forth In this Authorization, no wa".ntles, expressed or Implied, are made by the Funeral Home, Crematory or any of Ibdr rt.p<ciiv. efnilltlea, agents oremployets. U, i/We undcntand Ibot this document dots not contain a complete and derailed description of every a. t t of Ill. cremation proeeas. IrWc acknowledge receiving, from the Funeral Home. a copy of the booklet entitled "Cremation Facts" containing additional explanatory Information about the cremation process. SIGNATURE OF PERSON(S) AUTHORIZING CREMATION AND DISPOSITION 1/We warrant that all rep"sentallona and statement, made hcreln are true and rilriecl. and that 1/we have read and understand the provisions contained In Wit document, and that 11w. have received the booklet entitled "Cremetton Pactil Signature „•`;f Z4 :?F__ z - Rol Ts,.(- Koo.J'PZ S r•c r„ /z Adeirt, 3-r T',d2NtrL ST' CttrtlewAr:i rI. 3yf,/6 - 1. No. . (?1?) 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