Vital Statistics Form

Release Form
NAME OF DECEASED:*
DATE OF BIRTH:*
MM slash DD slash YYYY
AGE:*
LOCATION OF DECEDENT*
Place of death (Please put full address of location below.)
ADDRESS: LOCATION OF DECEASED:*
Street Address Address Line 2 City State ZIP Code
I undersigned hereby authorizes the release of the above named decedent to
CREMATION SOCIETY OF AMERICA to care and prepare for disposition. I hereby
represent that I am the nearest degree of relationship to the deceased.
Signed*
Legally Authorized Next of Kin*
Relationship to Deceased*
Witness Signature:*
Print Name*
CREMATION SOCIETY OF AMERICA

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