Mullins Memorial

1 1056 NE 7th Terrace, Cape Coral, Florida (239) 242-0909 3654 Palm Beach Blvd, Fort Myers, Florida (239) 288-7000 (855) 242-0909 FAX EMBALMING authorization I, the undersigned, hereby authorize Mullins Memorial Funeral Home & Cremation Service, Inc. including its agents and employees to embalm, care for and prepare for disposition the body of _____ in accordance with customary practices. I acknowledge and agree that this authorization permits the funeral home to use the services of third party embalmers (if out of our immediate service area) or apprentices or students enrolled in a mortuary school under the direct supervision of a licensed embalmer. I further acknowledge and agree that the embalming process may be performed at our funeral home or at a funeral home that is licensed under state law if the death occurred out of our immediate service area.

2 I represent that I have legal authority to grant this authorization . I also agree to indemnify and hold harmless the funeral home, its affiliates, their agents and employees from any and all liability or claims which may arise as a result of the authorization to Embalm and Prepare or any action taken in accordance herewith. _____ _____ Signature Relationship Signature Relationship