Going Home Cremation Services, Inc. 1120 S. Pinellas Bayway #202, Tierre Verde Florida 33715

    727-800-6819 or 941-320-1179. Fax 727-934-1529

    AUTHORIZATION FOR CREMATION & DESIGNATION OF INTENTIONS FOR DISPOSITION OF CREMATED

    REMAINS of : Deceased Name

    Date of Death   Weight   Pacemaker Y_   N

    The below line to be filled out by our office

    Time of Death Approx. completion date

    It is policy of Our Florida Crematory to require this form to be signed by the legally authorized person(s) in the order by law, 497.005(39), FS, before scheduling any cremation. I am a legally authorized person as defined by 497.005(39), FS. I request and authorize Florida Family Cremations, Inc., identified herein as “FH/DD,” to take possession of and make arrangement for the cremation of the remains of the Deceased at Florida Crematory, identified herein as “Crematory”. I attest that I am not aware of any person in priority class or higher who objects to this authorization. I acknowledge that no person can make a claim objecting to the cremation of the remains identified herein against Crematory when Crematory acts upon authorization of the legally authorized person executing this Authorization. Explanation of Cremation Process: Florida law requires that three conditions be met before a cremation can take place: (1) 48 hours has expired from the time of death, (2) Legally authorized person has given written permission, and (3) Medical Examiner’s office has approved the cremation. Once these conditions have been met, the Crematory will perform the cremation as soon as scheduling permits but no later than ten (10) business days from such date, excluding holidays. All cremations are performed individually. Cremation is performed by placing the deceased in a container and then placing the container into a cremation chamber where it will be subject to intense heat and flame reaching temperatures of approximately 1600-1800 degrees Fahrenheit. During the cremation process it may be necessary to open the cremation chamber and reposition the deceased in order to facilitate a complete and thorough cremation. After a typical time period of 1- 3 hours, all substances are consumed except bone fragments (calcium compounds) and metal (such as hinges, latches, dental implants, prosthesis, etc.) as the temperature is not sufficiently high enough to consume them. Accordingly, any such items which are left with the Decedent and not removed from the container will be destroyed or will otherwise not be recoverable. Following a cooling period, the cremated body, which will normally weigh several pounds in the case of an average size adult, is then swept or raked from the cremation chamber. The Crematory takes all reasonable steps and uses its best efforts to remove all the cremated remains, but it is impossible as some dust and other residue is always left behind. Due to this fact, inadvertent or incidental comingling of minute particles of the cremated remains from the residue of a previous cremation is a possibility during the cremation process or the processing stage (as described below) and the Undersigned understands and accepts this fact. After the cremated remains are removed from the cremation chamber, all noncombustible materials will be separated and removed from bone fragments by visible or magnetic selection. The Undersigned expressly authorizes the Crematory to send such non-combustible materials to a qualified company where some of those materials may be recycled and the remainder disposed of in a non-recoverable manner. The Crematory represents that any compensation it may receive from the recycling company for retrieving and shipping the non-combustible materials will be donated to a charitable organization of the Crematory’s choice. The bone fragments are then mechanically processed or pulverized into uniform particles to permit placement in the selected urn container for disposition indicated. The crematory makes a reasonable effort to put all of the cremated remains in the container with the exception of dust and other residue which may remain on the equipment. Procedures: I declare that all personal possessions have been or shall be removed from the Deceased by the next-of-kin/authorized representative and shall hold harmless, defend, and indemnify the Crematory, the FH/DD, or its agents and/or representatives from loss. The non-combustible items may be destroyed during the cremation process. We further authorize that any items, other than the cremated body of the deceased, recovered from the cremation chamber may be separated from the cremated remains and disposed of by the Crematory. Devices: Mechanical or radioactive devices in the deceased may create a hazardous condition when placed in the cremation chamber. It is imperative that these items be removed prior to cremation. In the event that these devices are present, Undersigned hereby authorize Crematory, and its agents and employees, to remove any such devices from the remains of the deceased prior to cremation. There may be a fee.

    Casket/Container: Florida law requires that the body of the deceased be delivered to the Crematory in a suitable container to provide dignity for the deceased and safety for the public and crematory personnel. This container must meet the following standards: (1) contain only permissible levels of chlorinated plastic, (2) be composed of readily combustible materials suitable for cremation, (3) be able to be closed to provide a complete covering for the deceased,(4) be resistant to leakage or spillage, and (5) be rigid enough for handling with ease. The Crematory reserves the right to reject a cremation container it determines not to be in compliance with the law and to remove and discard any handles or other objects which are non-combustible. Urn/Container: After processing, the cremated remains will be placed in a designated urn or container, which should have a minimum volume of 200 cubic inches. Crematory will make a reasonable effort to put all of the cremated remains in the urn or container. In the event the urn or container provided is insufficient to accommodate all of the cremated remains, the excess will be placed in a secondary container and will be handled according to the Designation of Intentions for Disposition instructions listed below: P a g e 2 | 2 Designation of Intentions for Disposition of Cremated Remains: I authorize the Crematory to release the cremated remains of the Deceased to the possession and custody of FH/DD and understand at that time, the services and obligations of the Crematory shall be fulfilled. I hereby authorize FH/DD to arrange for the disposition of the deceased as follows (check and initial one):

    Release to: Name Picked up at Crematory

    $95.Personal Deliver to: address

    $225.00 Mailed via U.S.P.O.

    Following proper delivery of the cremated remains to the US Post Office, Undersigned releases the FH/DD and Crematory from any further responsibility or liability for delivery to the ultimate destination. *Pursuant to Florida law, any cremated remains not picked up within 120 days shall be disposed of at the discretion of the FH/DD in any manner it seems suitable, including scattering in the Gulf of Mexico in a non-recoverable manner. SIGNATURE OF AUTHORIZED AGENT: By executing this Authorization for Cremation and Designation of Intentions for Disposition of Cremated Remains and initials where appropriate, Undersigned warrant that all representations and statements contained in this form are true and correct, that those statements are being relied upon by Crematory to cremate the human remains of the deceased, and that the undersigned have read and understand every provision contained in this document. Undersigned agree to indemnify, release and hold harmless Crematory, FH/DD, its agents, employees, representatives and assigns from any and all loss, damage, liability, costs, expenses or claims resulting from this Authorization, including attorney’s fees and costs of litigation in connection with the cremation and disposition, including shipping of the cremated remains; also for any loss to said cremated remains, occasioned by an act of God, common enemy, theft, strikes, riots, vandals, order of Military of Civil Authority, and for any other act beyond our control. *This document may be executed in any number of counterparts, each of which shall be deemed an original. Each may execute a facsimile counterpart signature page to be followed by an original counterpart. Each such facsimile counterpart shall constitute a valid and binding obligation of the signing party.

    1.
    SIGNATURE
    Relationship to decease
    PRINTED NAME/ DATE
    2.
    SIGNATURE
    Relationship to decease
    PRINTED NAME/ DATE
    3.
    SIGNATURE
    Relationship to decease
    PRINTED NAME/ DATE

    I have made the arrangements for cremation of the Deceased, identified above, with the legal next-of-kin and received all necessary signatures for this Authorization for Cremation.

    Date

    FUNERAL DIRECTOR OR DIRECT DISPOSER SIGNATURE PRINT NAME


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