Body Release & Cremation Authorization Form

1 body Release & Cremation Authorization FormI, the undersigned, certify, warrant and represent that I have full legal right and authority toauthorizeAllen & Shaw cremations , Lic# F041565 and/or their agents to remove, takepossession of, transport and arrange for the final disposition for the remainsof:_____, age_____ who died in_____County,Florida on the_____day of_____at_____am/pm. I, the undersigned,certify, warrant and represent that I have full legal right and authority to authorizeAllen & ShawCremationsto make arrangements for the Cremation and that the cremains be:( Pick up,Scatter at Sea or Ship)If pick up, who is authorized. If ship please write address. _____ _____ _____The Cremation shall be performed in accordance with all governing laws, rules, regulations and policies ofAllen &Shaw cremations , the crematory, the State of Florida and the following terms and The remains of the deceased must be in acombustible, leak resistant, rigid To prevent damage to the Cremation chamber, I authorize the removal of any type of implanted mechanical or radioactivedevices(suchaspacemakers, etc.)

2 3. The deceased will be cremated using the application of intense heat and flame and that the cremains, consisting primarilyof bone fragments will be mechanically processed to an unidentifiable consistency prior to placement in an urn or othercontainer. I further understand and acknowledge, that even with the exercise of reasonable care and the use of thecrematory's best efforts, it is not possible to recover all particles of the cremated remains remaining in the cremationchamber and/or devices used to process thecremated I understand that Florida Statute, Section (2) states that in the event that the cremains remain unclaimed for aperiod of 120 days, Allen & Shaw cremations is authorized and directed to dispose of the cremains in any lawful manner itmay seem I agree to indemnify, Release and hold Allen&Shaw cremations , the crematory, their affiliates, agents, employees andassigns,harmless from any and all loss, damages, liability or causes of action (including attorney's fees and expenses oflitigation) in connection with the Cremation and disposition of the cremains of the deceasedasauthorized signing below, I warrant that all representations and statements made herein are true andcorrect and that I have read and understand the provisions contained in this Name.

3 _____Signature _____Relationship:_____ Phone (include Area Code)_____Address:_____City_____State___ __Zip Code_____Allen & Shaw Cremations13931 NW 20th Court Opa Locka, FL 33054 Phone: 305-681-1426 or 800-681-1426 Fax: 305-687-4064 or