Vital Statistics Form

Release Authorization
NAME OF DECENDENT:*
DATE OF BIRTH:*
MM slash DD slash YYYY
DATE OF DEATH:*
MM slash DD slash YYYY
Does the decedent have implanted mechanical or radioactive devices? ie. pacemaker
- Yes
- No
Loc. # - Name of Funeral Home
I, the undersigned, hereby authorize and request,
release/transfer the remains of the Decedent to:
Address of Location Deceased:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I acknowledge and agree that this release authorization permits Cremation Society of America to use the services of other funeral home/affiliates or other independent contractors in connection with the transfer of the Decedent from the place of death or Funeral Home.

I represent that I have legal authority to give this authorization. I agree to indemnify and hold harmless Cremation Society of America, its affiliates and their agents and employees from any and all liability or claim which may arise as a result of this release authorization.
Signed*
Legally Authorized Next of Kin*
Relationship to Deceased*
Witness Signature:*
Print Name*

Clothing Release