The undersigned hereby request and authorizes, Island Cremations in accordance with and subject to its rules and regulations as well as those of the State of Florida, to cremate the remains of (Full Legal Name):

Date of Death __________________ Time of Death ____________ _AM _PM and that said remains are placed in a cardboard container or other type of container as specified: ______________.

The undersigned hereby authorizes Island Cremations to dispose of the said cremated remains as indicated below and understands that pursuant to Florida law that if final disposition of the cremated remains has not taken place within 120 days, then this instrument shall continue full and complete authority for said funeral home and crematory to dispose of the Cremains according to Florida law.

_____ Mail the Cremains to:
______________________________________ via registered mail and agrees to assume all liability for any damages that may arise from any cause of said delivery and to indemnify and hold harmless and blameless from any and all claims related to said delivery. Island Cremations fee for mailing is $150.00.

_____ Inter the Cremains in __________________________________ Cemetery. The Cemetery may have a charge (internment fee) for this service and you agree to pay for such charge by the time of the internment.

_____ Dispose of the Cremains in the Atlantic Ocean by boat or plane or other location __________________ Island Cremations fee for this service is $________.

_____ Store the Cremains for _____ months. Island Cremations fee for this is $50 per month.

_____ Return the Cremains to the family in a temporary container or in place in a (an) _____________ Urn.

I/We agree to hold Island Cremations, its servants and employees blameless and harmless from any and all liability whatsoever; also for any loss or damage to said cremated remains, occasioned by act of God, common enemy, theft, strikes, riots, vandals, order of Military and Civil Authority and for any other act beyond our control. Some heart pacemakers can be dangerous when placed in a cremation chamber. If the crematory does not receive proper notice, the family shall be held responsible for any damage resulting and the crematory will not be responsible or accept any liability under those circumstances.

the above named DOES _____ or DOES NOT _____ have a pacemaker.

I/We have read this authorization carefully before signing and swear that all the above statements are true. I/We represent and certify that the right to make such authorization as related to the deceased is vested in the undersigned.

Signed

Email: Relationship: Date

Printed Name: Phone:

Signed

Relationship: Date

Printed Name: Phone: