Authorization for Cremation and Disposition

Complete each step below. All information is kept strictly confidential.

Decedent Information

THIS AUTHORIZATION IS NOT A CONTRACT FOR CREMATION SERVICES. A separate contract is required to purchase the services of the Funeral Home and/or Crematory.

First Name *

Middle Name

Last Name *

Date of Birth *

Date of Death *

Time of Death

Place of Death

Sex

Social Security Number

How was the decedent identified? *

Because cremation is irreversible, Ohio law requires that the decedent be positively identified before cremation.

I (or my representative) viewed the decedent in person

I (or my representative) identified the decedent from a photograph or image

Identified by a scar, tattoo or other distinguishing mark (describe)

The Coroner or Medical Examiner identified the decedent

Does the decedent have a pacemaker, defibrillator, or any other implanted battery-powered or mechanical device? *

Examples: pacemaker, ICD, drug pump, neurostimulator, bone growth stimulator, programmable shunt, silicone implant. Joint replacements and dental work do not need to be listed here.

Yes

Within the last two years, did the decedent receive radioactive cancer treatment (for example, brachytherapy "seeds" or radioactive iodine)? *

Yes