Authorization for Cremation and Disposition

  • Step 1

Notice: This is a legal document. It contains important provisions concerning cremation. Cremation is the irreversible process of reducing human remains to bone fragments through open flame, extreme heat, and evaporation. Before signing this legal document, please read the attached Simpson Crematory policies, procedures, and requirements. You will be asked to sign this document. Should you have any questions, please direct them to your funeral service professional or to Simpson Funeral Home and Crematory.

Authorization and Identification

I (We), the undersigned (the "Authorizing Agent"(s) hereby authorize and request Simpson Funeral Home & Crematory, in accordance with and subjects to its Policies, Procedures, and Requirements, and any applicable state or local laws or regulations, to cremate the human remains and arrange for the final disposition of the cremated remains as set forth on this form.

Acknowledgements

I (we) understand that the Commonwealth of Virginia requires that before cremation can take place a signed death certificate must be received from the deceased's physician of record. I further understand that the crematory/funeral home staff will promptly deliver the death certificate to the physician. I also understand that prompt delivery of the death certifciate in no way guarantees that the death certificate will be signed immediately.

I (We) understand that I (or my personal representative) must visually identify the remains, a photograph of the remains, or other unique markings or identifiers on the remains. I understand that unless I arrange otherwise, the remains will be just as they were received from the hospital, nursing home, or other such facility.

I (We) elect to identify the human remains of the deceased in person at the funeral home.

I (We) give permission to the funeral home to photograph the human remains of the deceased for the purpose of identification.

I (We) give permission to the funeral home to photograph the human remains of the deceased for the purpose of identification.

I (We) Understand that the Medical Examiner must first sign CME form #5, Cremation or Burial at Sea Certificate after viewing the remains and reviewing the signed death certificate.

I (We) understand that the regulations of the Commonwealth of Virginia require that human remains be either embalmed or refreigerated at 40 degrees or less while in storage waiting for the death certificate and the Medical Examiner's authorization to be signed. The first period of 48 hours will be at no charge. Following the first 48 hour period of storage, a charge of $50. Per day will be made for any additional day(s) or any portion thereof.

I (We) understand that the Commonwealth of Virginia requires that human remains be placed ina  rigid, leak resistant container that includes a top cover. I have selected the (container to be selected) and understand that the remains will be in this container when the identification, family/or public viewing takes place

I Understand that the crematory does not offer storage of cremated remains and that I am required to pick up the cremated remains within a period not to exceed two weeks. After two weeks, I agree to pay a storage fee of $25.00 per day for the crematory to hold the cremated remains in safe keeping for a period not to exceed 14 days. After 120 days I understand that the crematory will dispose of the cremated remains in any manner that they find acceptable.

Some heart pacemakers, other battery operated or radiation producing implants and other life sustaining devices can be explosive and very dangerous when placed in a cremation chamber. Simpson Crematory requires that all such devices be removed before the remains are delivered to the crematory. The undersigned assumes all liability and will be held responsible for any and all damages to the crematory or injuries to crematory personnel should the crematory not be notified in advance of the presence of such a device.

Pacemakers, Prostheses, and Radioactiuve Implants
Witnessing

The crematory does not provide an urn or any type of permanent container for the cremated remains. You must provide, with the assistance of your funeral service professional, some type of urn or permanent container. If you do not choose or provide an urn, the cremated remains will be returned to you in a simple cardboard box. The merchandise I have selected or chosen to use are described as follows:

Merchandise

After the cremation has taken place, the cremated remains have been processed and the processed cremated remains placed in the designated urn or permanent container, the crematory will arrange for the disposition of the cremated remains as follows, and the Authorizing Agents(s) hereby authroize the crematory to release, deliver, transport, or ship the cremated remains as specified

Final Disposition

Where to ship cremated remains

Limitation of Liability

As the Authorizing Agent(s), I (we) hereby agree to indemnify, defend, and hold harmless Simpson Funeral Home and Crematory, Inc., its agents and employees, of and from any and all claims, demands, causes or causes of action of every kind, nature and description, in law or equity, including any legal fees, costs and expenses of litigation, arising as a result of, based upon, or connected with this authorization, including the failure to properly identify the decedent or human remains trnasported to Simpson Funeral Home & Crematory, the processing, shopping, and final dispostion of the decedent's cremated remains, the failure to take possession of or make proper arrangements for the final disposition of the cremated remains, any damage due to harmful or explodeable implants, claims brought by any other person(s) claiming the right to control the disposition of the decedent or the decedent's cremated remains, or any other action performed by Simpson Funeral Home & Crematory, it's officers, agents, or employees, pursuant to this authorization, excepting only acts of willfull negligence. I (we) the undersigned understand this document does not contain a complete and detailed description of every aspect of the cremation process. I (we) acknowlege receiving from the funeral home and crematory a copy of the brochure entitled "Policies, Procedures and Requirements" containing additional explanatory information about the cremation process.

THIS IS A LEGAL DOCUMENT; IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING

Signature of Authorizing Agent(s)

Therefore, I(we), the undersigned, hereby certifiy that I (we) am (are) the closest living next of kin of the decedent and that I am related to the deceased as his/her:

or that I otherwise serve (served) in the capacity of

to the decedent, that I have charge of the remains of the decedent and as such possess full legal authority and power, according to the laws of the Commonwealth of Virginia, to execute the authorization form and to arrange for the cremation and disposition of the cremated remains of the decedent. In addition, I am aware of no objections to this cremation by any spouse, child, parent, sibiling, or any other person.

By executing this Cremation Authorization Form, as Authorizing Agent(s), the undersigned warrant that all representations and statements contained on tis form are true and correct, that these statements were made to induce Simpson Funeral Home & Crematory to cremate the human remains fo the decedent and that the undersigned have read and understand the provisions contained on this form and the accompanying Policies, Procedures, and Requirements.

Authorizing Agent #1

Address

Authorizing Agent #2

Address

Authorizing Agent #3

Address

Please wait