CREMATION AUTHORIZATION

 Wherity Family Funeral and Cremations
8265 Southwest Seneca, Tualatin, OR 97062
Ph 503.885.8242   fax 503.885.9430

AUTHORIZATION

I (We), the undersigned (the” Authorizing Agents(s)”), hereby request and authorize the above named service (hereinafter referred to as “Funeral Establishment”) to take possession of and make arrangements for the cremation of the decedent named below (the “Decedent”) in accordance with and subject to the provisions set for the in this document, at______________________________ (hereinafter referred to as the “Crematory”) and in accordance with and subject to their rules and regulations, and subject to any applicable state or local laws or regulations.

Name of Deceased 

     Sex     Male Female

Date of Birth

Month

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Day

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year

2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1968 1967 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Date of Death

Month

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Day

01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Year

2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1968 1967 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Funeral Establishment Representative _________________________________________

PACEMAKER AND RADIOACTIVE IMPLANTS

Mechanical, radioactive devices or implants in the decedent may create a hazardous condition when placed in a cremation chamber.   ALL PACEMAKERS AND RADIOACTIVE IMPLANTS MUST BE REMOVED PRIOR TO DELIVERY OF THE DECEDENT TO THE CREMATORY.
Has the deceased been treated with Metastrone, which contains Strontium-89?   No Yes   Initial(s) ____________

The decedent’s remains do not contain a pacemaker, radioactive implant or other device that could be harmful to the crematory.  They are safe to cremate.  Initials(s) ___________

The following list contains all existing devises implanted in or attached to the decedent that should be removed prior to cremation: _____________________________________________________________________
We have arranged for the Funeral Establishment to remove or arrange for the removal of these devices and to properly dispose of them prior to cremation.  I understand that if the Funeral Establishment has not been notified about such devices or implants, and not instructed to remove them, that I/We am/are responsible for damages caused to the Crematory, or crematory personnel by such implants or devices.

CREMATION PROCESS

Cremation is a technical process using heat and flame that reduces human remains to bone fragments.  The reduction takes place through heat and evaporation.  Cremation shall include the processing, and may include the pulverization of bone fragment.  The human body burns with the casket, container, or other material in the cremation chamber.  Some bone fragments are not combustible at the incineration temperature and, as a result, remain in the cremation chamber.  During the cremation, the contents of the chamber may be moved to facilitate incineration.  The chamber is composed of ceramic or other materials, which disintegrates slightly during each cremation and the product of that disintegration is commingled with the cremated remains.  Nearly all of the contents of the cremation chamber, consisting of the cremated remains, disintegrated chamber material and a small amount of residue from previous cremations, are removed together and crushed, pulverized, or ground to facilitate inurnment or scattering.  Some residue remains in the cracks and uneven places of the chamber.  Initial(s) ___________

CASKET/CONTAINERS

The Crematory requires either a casket or an alternative (cremation) container for the cremation.  The above named Funeral Establishment does not offer metal caskets for cremation.  All caskets and alternative containers must meet the following standards:  (1.)  Be composed of materials suitable for cremation; (2.)  Be able to be closed to provide a complete covering for human remains; (3.) Be sufficient for handling with ease; (4.)  Be resistant to leakage or spillage; (5.)  Be able to provide protection for the health and safety of crematory personnel.  The crematory is authorized to inspect the casket or alternative container, including opening if necessary.  In the event there is leakage or damage, the Crematory may contact the Funeral Establishment directly for instructions.  The Crematory reserves the right to open the casket or alternative container to verify the identity of the deceased.  Many caskets that are comprised of combustible materials also contain some exterior parts, e.g., decorative handles or rails that are not combustible and may cause damage to the cremation equipment.  The Crematory, at its sole discretion, reserves the right to remove these non-combustible materials prior to cremation and to discard them with similar materials from other cremations and other refuse in a non-recoverable manner.
Type of casket or cremation container selected

URNS/TEMPORARY CONTAINERS

After the cremated remains have been processed, they will be placed in the designated urn or container.  The Crematory will make a reasonable effort to put all of the cremated remains in the urn or container, with the exception of dust or other residue that may remain on the processing equipment.  In the event the urn or other container selected is insufficient to accommodate all of the cremated remains, the excess will be placed in a separate receptacle.  The separate receptacle will be kept with the primary receptacle and handled according to the disposition instructions on the form.  Crematory requires that all urns or containers provided be appropriate for shipping or permanent storage, and that in case of an adult, it is recommended that the urn or container be a minimum of 200 cubic inches.  Unless a suitable urn is provided for the cremated remains, the Crematory will place the cremate remains in a container provided by the Crematory. 
Type of urn or container selected:

Engraving:   No Yes   Engrave exactly as shown on the engraving form (available by request, call 503.885.8242)

WITNESSED CREMATIONS

The cremation will take place after civil and medical authorities have issued permits, all necessary authorizations have been obtained, and no legal objections have been raised, and after any schedules funeral ceremonies or viewing have been completed.  The Crematory, or authorized agents, is authorized to perform the cremation upon receipt of the human remains, at its discretion, and according to its own schedule, as work permits, without obtaining any further authorization or instructions.  All cremations are performed individually.  The Crematory will only place the human remains of one individual in the chamber at a time.

Are there any people who wish to witness the casket or container being placed in the crematory chamber?  No Yes
If yes, please provide the names of those individuals who wish to witness on the separate release form. (available by request, call 503.885.8242)

DISCLOSURES AND PERMISSIONS

Initial(s) ___________I/We certify that the deceased person named above has not giving other specific directions concerning the disposition of his/her remains.
Initial(s)___________I/We the undersigned, hereby certify that I/We am/are the closest living next of kin of the Decedent and that I/We are related to the Decedent as his/her_____________________________, or that I/We otherwise serve (served) in the capacity of __________________________________________to the Decedent, that I/We have charge over the remains of Decedent and such possess full legal authority and power, according to the laws of the state to execute this authorization form and to arrange for the cremation and disposition of the cremated remains of the Decedent.  In addition, I/We am/are aware of no legal objection to this cremation by any spouse, child, parent or sibling.
Initial(s)_____________I/We authorize that if any non-combustible items, other than the cremated remains of the decedent, are recovered from the cremation chamber, they may be separated from the cremated remains of the deceased, and disposed of by the Crematory.
Initial(s) ____________ I/We understand that if I/We wish to remove and/or retain any items from the remains, I must do so directly or by authorized agent prior to the cremation process.

DISPOSITION OF THE CREMATED REMAINS

I/We authorize the Crematory to return the cremated remains of the decedent to the possession and custody of the Funeral Establishment.  I/We understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the Decedent are returned to the possession and custody of the Funeral Establishment.  I/We hereby arrange for the disposition of the cremated remains of the decedent as stated below:
Initial(s)____________I/We understand that in the event the cremated remains have not been permanently interred or picked up by me or my designated representative within 180 days from the date of cremation, I/We hereby authorize the Funeral Establishment to lawfully dispose of the cremated remains.

I HEREBY DIRECT AND AUTHORIZE THE RELEASE/DELIVERY OR SHIPMENT OF SAID CREMATED REMAINS.
Initial(s) ____________.  Deliver the said cremated remains to
For the purpose of:

Initial(s)____________.I appoint the Funeral Establishment my agent to make shipment of said cremated remains via U.S. Postage Mail (registered, return receipt), or scheduled air shipment (PROPER CONTAINER OR URN REQUIRED BY COMPANY).  I am aware that the Funeral Establishment’s services have been fully completed when the cremated remains leave the Funeral Establishment and that the Funeral Establishment is only acting as my agent for my accommodation only in carrying out these instructions.  I understand that the Funeral Establishment assumes no responsibility after delivery to the Post Office, common carrier or agent.
Ship to:

RIGHT TO CONTROL DISPOSITION

Oregon Revised Statues 97.130(2):  A person within the first applicable listed class among the following listed classes that is available at the time of the death or, in the absence of actual notice of a contrary direction by the decedent as described under section (1) of this section or actual notice of opposition by completion of a written instrument by a member of the same class or a member of a prior class, may direct any lawful manner of disposition of a decedent’s remains by completion of a written instrument.

SIGNATURE OF AUTHORIZING AGENT(S)

THIS IS A LEGAL DOCUMENT.  IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.  CREMATION IS IRREVERSIBLE AND FINAL.  READ THIS ENTIRE DOCUMENT CAREFULLY BEFORE SIGNING.
By executing this cremation authorization form, as Authorizing Agent(s), the undersigned warrants that all representations and statements contained on this document are true and correct, that these statements were made to induce the above named Funeral Establishment and Crematory to cremate the human remains of the Decedent, and that the undersigned have read and understand the provisions contained on both pages of the document.

 Executed at_______________________________, this___________day of ____________________, 20____.

Name_______________________________________  Signature_______________________________________

Relationship___________________________________  Phone No._____________________________________

Name_______________________________________  Signature_______________________________________

Relationship___________________________________  Phone No._____________________________________

Name_______________________________________  Signature_______________________________________

Relationship___________________________________  Phone No._____________________________________

Name_______________________________________  Signature_______________________________________

Relationship___________________________________  Phone No._____________________________________

Witness: ______________________________________________________________