AUTHORIZATION FOR CREMATION AND DISPOSITION

1 DATE OF DEATH: _____ TIME OF DEATH: _____ FD OK: _____ AUTHORIZATION FOR CREMATION AND DISPOSITION NOTICE: THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION . CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING. I/We, the undersigned, certify, warrant and represent that I/we, have the full legal right and authority to authorize the CREMATION , processing and DISPOSITION of the remains of _____ (hereinafter referred to as the "Deceased") Name of Deceased I/We hereby request and authorize Illinois CREMATION Centers (hereinafter referred to as the "Funeral Home") to take Name of Funeral Home possession of and make arrangements for the CREMATION of the remains of the Deceased at Forest Crematory (hereinafter referred to as the "Crematory").

2 I/We authorize the Crematory to return the cremated remains of the Deceased to the possession and custody of the Funeral Home. I/We understand that services and obligations of the Crematory shall be fulfilled when the cremated remains of the Deceased are returned to the possession of the Funeral Home. I/We authorize the Funeral Home to arrange for the DISPOSITION of the cremated remains of the Deceased as follows: Is special handling required? Yes No Describe: _____ _____ Description of urn or container selected: _____ Suitable for shipping: Yes No Deliver to _____ Cemetery Name and Address of Cemetery Release to family _____ Names of designated Family Members to Receive Cremated Remains Ship via _____ To: Name _____ Address: _____ Other _____ The death did did not occur from a disease declared by the Department of Health to be infectious, contagious, communicable, or dangerous to the public health.

3 The CREMATION processing and DISPOSITION of the remains of the Deceased authorized herein shall be performed in accordance with all governing laws, the rules, regulations and policies of the Crematory and Funeral Home, and the following terms and conditions: 1. Mechanical or radioactive devices implanted in the remains of the Deceased ( such as pacemakers, etc. ) may create a hazard when placed in the CREMATION chamber. The Crematory will not cremate any human remains which contain any type of implanted mechanical or radioactive device. In the event the remains of the Deceased contain such a device, I/we hereby authorize the Funeral Home, its agents and employees, to remove any such mechanical devices from the remains of the Deceased prior to CREMATION and dispose of such items at its discretion.

4 I/WE HEREBY CERTIFY THAT THE REMAINS OF THE DECEASED DO DO NOT CONTAIN ANY TYPE OF IMPLANTED MECHANICAL OR RADIOACTIVE DEVICE. Listed 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 indicated: _____ _____ Description of Implanted Device DISPOSITION If no instruction for DISPOSITION is given, such items may be disposed of at the discretion of the Funeral Home. Terms and Conditions continued on next page _____ (Initials) All of the above and the back has been read and understood. Terms and conditions are an integral part of this AUTHORIZATION .

5 SIGNATURE OF PERSON(S) AUTHORIZING CREMATION AND DISPOSITION I/We warrant that all representations and statements made herein are true and correct and that I/we read and understand the provisions contained in this document, and that I/we have received the booklet entitled " CREMATION Facts". Signature _____ Print Name Relationship to Deceased Address _____ Tel. No. (____) __ _____ Street City State Zip Signature _____ Print Name Relationship to Deceased Address _____ Tel. No. (____) _____ Street City State Zip WITNESS _____ Date: _____ Signature Print Name Subscribed and sworn before me this _____ day of _____ Notary Signature _____ _____ My commission expires _____ Illin ois CREMATION Centers 1000 Rohlwing Rd.

6 , Suite 4, Lombard, IL 60148 877-368-7005 Name, address and phone of Funeral Home Revised: 08/1/12 (Please initial one) (Imprint Notary seal) (Date) Continued From Page 1: The c remation, pro cessing and disposit io n of th e remains of the Dece ased authorized herein shall be performed in accor dan ce with all governin g laws, the rul es, regula tio ns and p olic ies of the Crematory and Funeral Ho me, and the follow ing term s a nd co nditi ons: 2. The remain s of the Decea sed will not b e accepted f or crematio n unless received b y the C rematory in a co mbu stibl e, leak resis tan t rigid CREMATION container.

7 The Crematory is a uthorized to remove and di spose of han dles, ornaments a nd any o ther n oncombustib le ite ms attached to the CREMATION contain er p rio r to crematio n. I n th e event th e remains of th e Deceased are recei ved b y the Cremato ry in a c asket or other container construct ed of m etal, fib erg lass, or other n oncombu stibl e mate rials, I/we authorize the remains o f th e De ceased to be re moved prior to crematio n and placed in a combustible cr ematio n container. I/We furth er auth orize the Fun eral Ho me or Crematory to make dispositio n of an y such noncombustibl e casket in any law ful manne r it d eem s ap propri ate.

8 3. The CREMATION container containin g the remain s of th e Deceased will be placed in the cr ematio n chamber and will be to tally and irr eve rsibl y destroye d b y prol onged exposure to intense heat and direct fl ame. I/We auth orize the C rematory to ope n the C rematio n chamber during the CREMATION process a nd repositio n t he remains of the Deceased in order to facilitate a compl ete and thorou gh CREMATION . 4. Certain items, inc lu din g, but not limit ed t o, body prost heses, dentu res, dental bridgework, dental fillin gs, jewe lry, a nd other p ersonal arti cles acc ompan yin g the remain s of the De ceased , may be destroyed during the cr ematio n process.

9 I/We furth er auth orize that if a ny items, oth er than cremate d remain s of the Deceased, are recovered from th e crematio n chamber, they may be separated fr om the cremated r ema ins of th e De ceased and dispose d of by the Crematory. 5. I/ We hereby au th orize the Crematory to separate and remove from the CREMATION c hamber all noncombustib le materials, including, but not limit ed to , hin ges, latch es, nails, jewelry a nd pr eciou s m etals, and to d is pose o f such materi als. 6. Fo llo wing crematio n, the cremated r emains of the Deceased, co nsis tin g primaril y of bone fragments, will be mech anicall y pulverized to an unid entifi able consisten cy prio r to p lacem ent in an urn o r other containe r.

10 7. Unl ess a n urn or container suitab le for shipm ent is purchased or suppli ed, the C rematory will p lace t he cremated remains of the Deceased in whi cheve r urn the famil y c hooses wh ich m ay not be designed for any type of shipment. 8. I n the eve nt th e urn or container i s in suffi cient to accommo date a ll of the cr emated r emains of th e Deceased, any excess cremated human remains w ill be dispose d o f in any non-r etrievable manne r as permit ted b y law. 9. I/We understand and acknowle dge, that eve n with the exe rcise of reasonable car e and the use of the C rematory's best efforts, it is not poss ible to recover all part ic les of the cr emated remains of the Deceased, and that some partic les may inadve rtentl y beco me commi ngled with particl es of oth er cremated r emains remaini ng in the CREMATION chamber and/o r other devices util ized to process the cr emated remains.