Funeral Director’s Service LLC
504 National Ave. Indianapolis, IN 46227
Cremation Authorization
The Undersigned as Authorizing Agent; Name______
Signature______
Relationship______
Address______
______Phone______
As authorizing agent, I hereby authorize:
Whispering Hope Crematory
625 Progress Parkway Shelbyville, IN 46176
To Cremate the Remains of:
Name of Decedent______
Last Known Residence______
Time & Date of Death______
Acting under Indiana Code 23-14-31-27, the Authorizing Agent hereby certifies:
1. The undersigned warrants that (he/she) has known the decedent and that the remains show (him/her) is that of the decedent.
2. He/She has the right to authorize the cremation of the decedent and no other person has a superior right, except: ______. In the event that an individual exists having superior right to execute this form, the Authorizing Agent certifies that all reasonable attempts have been made to contact such person, but has not been able to make contact, and believes that such person would not object to cremation.
3. WHISPERING HOPE CREMATORY is hereby given permission to cremate the decedent’s remains. Cremation may occur at any time after 48 hours after time of death, or at ______which is also 48 hours after time of death.
4. The decedent’s remains do not contain a pacemaker or any other material or implant or radiation producing device that might be potentially dangerous to the cremation chamber of any person attending the cremation.
5. The Funeral Director authorized to receive the cremated remains is: ______
6. The means of final disposition of the cremated remains will be (inurnment, scattering, interment, …) ______
If the Authorizing Agent does not specify the means of final disposition and fails to indicate the return of the remains to the Authorizing agent, the remains may be held by the crematory authority for not longer than 30 days after cremation at which time they will be returned to the funeral home who is required to hold them for not more than 60 days from the date of cremation prior to disposing of them as previously authorized or in any lawful manner.
7. A list of valuable items belonging to the decedent and now being held by the funeral home is: ______
8. The Authorizing Agent understands that the crematory may not sell non-organic material recovered from the decedent’s remains.
9. The Authorizing Agent previously has made arrangements for viewing the decedent prior to cremation, or for a service with the decedent present prior to cremation: those arrangements are: ______
10. The Authorizing Agent authorizes the crematory to proceed with cremation on receipt of the decedent’s remains, or after: ______, but in no event sooner than 48 hours after the time of death.
11. The Undersigned, as Authorizing Agent, assumes responsibility for the final disposition of the cremated remains of the decedent and certifies to the truth and accuracy of all information set forth on this Cremation authorization.
12. I request, and it is my authority, to deliver the cremated remains of the late ______, to ______.
I certify and represent that I have the full power and right to make such authorization. I hereby agree to assume any and all Liability for cost or damages arising because of such delivery and release the crematory from any and all liability that might attach thereto by reason of said delivery to said above party.
****** Initial ______******
I AFFIRM under the penalties of perjury that all the information set forth on the cremation Authorization form is true and correct and the cremation may proceed as authorized.
Signed at:______
This _____ day of ______. In the year ______.
Authorizing Agent ______
The undersigned, a licensed funeral director in the state in Indiana and authorized representative of ______;
Hereby certifies that the Authorizing Agent signed the Cremation Authorization Form on the date and at the place indicated thereon and further, that the remains delivered to the Crematory Authority are the same as those identified on the Cremation Authorization Form.
Date______Licensed Funeral Director______
Indiana Funeral Director License FD20600082
Indiana Funeral Home License No. 83003205