Cremation and Disposition Authorization


Walker Sanderson Tribute Center – Funeral Home and Crematory
This authorization form must be completed and signed prior to the cremation. Please read it carefully and ask us any questions you may have. Cremation is an irreversible and final process. It is important that you understand the cremation process that is described in section 8 of this authorization form prior to signing it. We want you to fully understand the information provided in the authorization form, so we will be pleased to answer any questions about the cremation process or other information in this form.
This authorization is not a contract for cremation services. A separate contract or contracts will be required to purchase the services of the Funeral Home and/or Crematory.

*Required fields




*Name of Submitter:

*Email Address of Submitter:

1. Identification of the Decedent:

Name of Decedent:

Date of Death:

Time of Death:

Place of Death:

Sex:

Date of Birth:

Social Security Number:

Because cremation is irreversible, identification of the Decedent is required by one of the following options: The Authorizing Agent has viewed the remains and positively identified them as the body of the Decedent.
The personal representative of the Authorizing Agent has viewed the remains and positively identified them as the body of the Decedent.
The Authorizing Agent has authorized the Funeral Home to utilize a photograph of the remains and the Authorizing Agent has positively identified the photograph as that of the Decedent.

2. Funeral Home and Crematory:

Funeral Home: Walker Sanderson Tribute Center, 85 East 300 South, Provo, UT 84606
Crematory: Central Utah Cremation Services, 85 East 300 South, Provo, UT 84606

3. Identification of Authorizing Agent:

Name of Authorizing Agent:

Relationship to Decedent:

Address:

Phone:

4. Authority of Authorizing Agent (See Section 4 below):

As Authorizing Agent, I represent that I have the right to authorize the cremation of the Decedent by one of the following three options: I certify that I do not have actual knowledge of any living person who has a superior right to act as the Authorizing Agent.
There is another living person(s) listed below who has a superior or equal right to act as Authorizing Agent. That person(s) has provided me written permission to serve as Authorizing Agent.
There is another living person(s) listed below who has a superior or equal right to act as Authorizing Agent. I have made all reasonable attempts to contact that person(s), but have been unable to do so. I have no reason to believe that such person(s) would object to the cremation of the Decedent’s Remains.

Name(s) of other Person(s):

5. Pacemakers, Implants and Prostheses (See Section 5 below):

Choose one of the following options:
The remains of the Decedent do not contain any of the devices described in Section 5
As Authorizing Agent, I instruct the Funeral Home to remove each device listed below and to charge for its services in making or arranging for such removal prior to cremation. Funeral Home will dispose of all such devices.

Description of Devices:

6. Casket or Alternative Container – No Metal Caskets Allowed (See Section 6 below):

Choose one of the following options:
Alternative Container
Wood Casket

7. Witness Cremation:

Choose one of the following options:
No Witnesses
Witnesses

List Witnesses below:

8. The Cremation Process (See Section 8 below):

9. Authorization to Cremate, Process and Pulverize:

As authorizing Agent, I have read and do understand the description of the cremation process contained in Section 8 below and authorize the Cremation Processing and Pulverization of the remains of the Decedent. I further authorize the Funeral Home to deliver the Decedent's remains to the Crematory for the purpose of the Cremation.

Yes

10. Urn or Temporary Container (See Section 10 below):

Choose one of the following:
Temporary Plastic Urn
Urn selected by Authorizing Agent

Description of Urn:

11. Final Disposition (See Section 11 below):

Choose one of the following options: The Funeral Home will receive the Cremated Remains of the Decedent from the Crematory
The Funeral Home shall deliver the Cremated Remains of the Decedent for disposition as follows:

Deliver to:

Ship to:

(Funeral Home and Crematory are not responsible for any loss or damage of Cremated Remains shipped via Registered Mail, United States Postal Service.)

12. Personal Property:

All personal property and effects delivered with the Remains of the Decedent to the Crematory, including jewelry, clothing, hair pieces, dental bridgework, eyeglasses, and shoes, will be destroyed in the cremation process or otherwise discarded by the Crematory, at its sole discretion.

13. Viewing and Funeral Ceremonies:

Prior to the cremation of the deceased, the Authorizing Agent or the Decedent's family has arranged for a Visitation and/or Funeral as set forth below:

Date:

Time:

Place:

14. Time of Cremation:

The Crematory will perform the cremation of the Decedents remains at a time and date as its work schedule permits without any further notification to the authorizing agent.

15. Certification and Indemnification:

The Authorizing Agent acknowledges that the Funeral Home and Crematory are relying upon the representations being made by the Authorizing Agent in the authorization. The Authorizing Agent certifies that all of the information and statements contained in the authorization are accurate and no omissions of any material fact have been made. The Authorizing Agent agrees to indemnify and hold harmless the Funeral Home and the Crematory, their officers, directors, employees and agents from any and all claims, demands, actions, causes of action or suits of any kind or nature whatsoever, including, but not limited to any legal fees arising out of or resulting from the Funeral Homes and the Crematory’s reliance on or performance consistent with the directions, statements, representatives and agreements contained in the authorization.

Executed at:

Date:

Signature of Authorizing Agent:

Relationship to Decedent:

Address:

Phone:

Driver's License Number:

Witness:

4. Authorizing Agent Priority List of those who can authorize a cremation under Utah law in order of priority (1 thru 9) 1. The decedent may authorize his or her cremation by providing written cremation directions which include the name and address of the decedent, the date the written directions were prepared and signed, the signatures of the decedent and the signature of at least two unrelated individuals who witnessed the signing of the form. The written directions may also be included in a will of the decedent. 2. The decedent during his or her lifetime may sign a written instrument which designates a person to arrange the cremation of the decedent’s remains. The written instrument must contain the name and address of the decedent, the name and address of the person designated to arrange the cremation, the date the written instrument was prepared and signed, the signature of the decedent and the signatures of at least two unrelated individuals who witnessed the signing of the form by the decedent. 3. The surviving legally recognized spouse of the decedent. 4. The surviving child or the majority of the surviving children of the decedent over the age of 18. 5. The unanimous consent of the surviving parent, parents or lawful custodian of the decedent. 6. The person or persons in the degree of succession under Utah title 75, chapter 2, interstate succession and wills. 7. Any public official charged with arranging the disposition of deceased persons. 8. A person or persons whom the funeral service director reasonably believes is entitled to control the disposition. 9. In the absence of any persons under sections 1 through 8 above, any person willing to assume the right and duty to control the disposition.

5. Pacemakers, Implants, and Prostheses Pacemakers, radioactive, silicon or other implants, mechanical devices or prostheses may create a hazardous condition when placed in the cremation chamber and subjected to heat. as authorizing agent, I have listed in #5 on the reverse side all devices (including mechanical, prosthetic, implants, or materials) which may have been implanted in or attached to the decedent.

6. Casket or Alternative Container The remains are to be cremated in a combustible casket or alternative container that is capable of being completely closed, is resistant to leakage or spillage, is sufficiently rigid to be handled easily and provides protection for the health and safety of crematory and funeral home personnel. The crematory is authorized to inspect the casket or alternative container, including opening it if necessary. In the event that the casket or containers does not meet the above requirements, the crematory will notify the funeral home and/or authorizing agent. Many caskets that are comprised primarily of combustible material also contain some exterior parts (decorative handles or rails) that are not combustible and that may cause damage to the cremation equipment. As authorizing agent, I authorize the crematory, in its discretion, to remove and discard the non-combustible materials. I understand that metal or fiberglass caskets will not be allowed for cremation. I further understand that the casket or alternative container will be consumed as part of the cremation process.

7. Witness Witnessing a cremation can be an emotional experience. Witnesses are assuming the risks involved and full release the funeral home and crematory from any liability. To the extent permitted by the crematory. The person listed on the reverse side are authorized to be present at the cremation room prior to and during the cremation of the decedent’s remains and during the removal of the cremated remains from the cremation chamber if you desire to witness. You must initial #7 on the reverse side and list their names.

8. The Cremation Process The cremation of the decedent’s remains may take place before or after ceremonies to memorialize the decedent. Cremation is performed to prepare the remains of the decedent for final disposition. It is carried out by placing the decedent’s remains in the casket or alternative container which is then placed into a cremation chamber or retort where they are subjected to intense heat and flame. All cremations are performed individually. During the cremation process, it may be necessary to open the cremation chamber and reposition the remains of the decedent in order to facilitate a complete and thorough cremation. Through the use of suitable fuel, the incineration of the container and its contents is accomplished and all substances are consumer or driven off, except bone fragments (calcium compounds) and metal (including dental gold and silver and other non-human materials) as the temperature is not sufficient to consume them. Due to the nature of the cremation process, any personal possessions or valuable materials, such as gold or jewelry (as well as anybody prostheses or dental bridgework) that are left with the remains and not removed from the casket or container prior to cremation may be destroyed or if not destroyed, will be disposed of by the crematory. The authorizing agent understands that arrangements must be made with the funeral home to remove any such possessions or valuables prior to the time that the remains of the decedent are transported to the crematory. Following a cooling period, the cremated remains, which will normally weigh several pounds in the case of an average-size adult, are then swept or raked from the cremation chamber although the crematory will take reasonable efforts to remove all of the cremated remains from the cremation chamber, it is impossible to remove all of them, as some dust and other residue from the process will be left behind. In addition, while every effort will be made to avoid commingling, inadvertent commingling of minute particles of cremated remains from the residues of previous cremations is a possibility, and the authorizing agent understands and accepts this fact. After the cremated remains are removed from the cremation chamber, all non-combustible material (insofar as possible) such as dental bridgework and hinges, latches, nails and screws from the container will be separated and removed from the human bone fragments by visible or magnetic selection. The crematory is authorized to dispose of these materials with similar materials from other cremations in a non-recoverable manner so that only human bone fragments will remain. When the cremated remains are removed from the cremation chamber, the skeletal remains often will contain recognizable bone fragments. Unless otherwise specified, after the bone fragments have been separated from the other material, they will be mechanically pulverized. The process of crushing or grinding may cause incidental commingling of the remains with the residue from the processing of previously cremated remains. These granulated particles of unidentifiable dimensions, which are virtually unrecognizable as human remains, will then be placed into a designated container.

10. Urn or Temporary Container After the cremated remains have been processed, they will be placed in the urn listed on the reverse side or, if an urn is not provided to the crematory, then in a temporary utility container provided by the crematory. The authorizing agent acknowledges that it is impossible to recover all of the dust and residue. In the case of an adult, it is recommended that the urn or temporary utility container be a minimum size of 230 cubic inches, in the event the urn or temporary containers is insufficient to accommodate all of the cremated remains. The excess will be placed by the crematory in a secondary container. This secondary container will be kept with the urn of the temporary container and handled according to the final disposition instruction set forth in section 11 below. Provided, however, that the secondary container may not be designed for shipping, all urns or containers provided to the funeral home or crematory must be appropriate for shipping. The authorizing agent directs the crematory to use the specified urn or container listed in #10 on the reverse side.

11. Following the cremation, the authorizing agent directs the crematory and/or funeral home to undertake the actions set forth on the reverse side to arrange the final disposition of the cremated remains of the decedent. If the cremated remains are shipped at any time, the authorizing agent directs that the crematory or funeral home utilize registered U.S. Mail with a return receipt or a shipping service that uses an internal system for tracing the location of the cremated remains during shipment and requires a signed receipt of the person taking delivery of the cremated remains. The authorizing agent understands that if no arrangements for the final disposition, release or shipment of the cremated remains are made in this authorization, the crematory and/or the funeral home shall hold the cremated remains for thirty (30) days after cremation. If during that thirty (30) day period the cremated remains are not retrieved by the person designated above to receive them or by the authorizing agent, or if arrangements for their final disposition are not made, then the crematory or funeral home may return the cremated remains to the authorizing agent at the address listed in section #3. in the alternative, if no arrangements for the final disposition of the cremated remains have been made within sixty (60) days after the cremation and if the authorizing agent has not taken delivery of or caused the delivery of the cremated remains, or in the event the arrangements of the final disposition have not been carried out within the sixty (60) day period because of the inaction of a party other than the crematory or funeral home, then the crematory or funeral home may dispose of the cremated remains in a grave, crypt or niche. The authorizing agent shall be liable for the cost of such final disposition in a grave, crypt or niche and shall reimburse the crematory or funeral home immediately upon receipt of an invoice.