Authorization for Cremation and Disposition of Remains

Name of crematory
Broder Cremation or DBGW Cremations
Name of funeral establishment in charge of arrangements.
Bi-State Cremation & Funeral Service
Larry T. Byndon funeral director in charge of arrangements
Missouri License # 2001015772
Illinois License Number 034.015861
I, the undersigned, herby authorize the crematory and funeral establishment named above to cremate the remains of:

Name of Deceased*

First Middle Last

I hereby certify that I have the legal right or am charged to authorize the cremation and the disposal of the cremated remains. I understand that due to the nature of the cremation process any valuable metals including dental gold, will be destroyed or not be recoverable. Any personal possessions accordingly have either been removed or may be destroyed. I further agree that I will indemnify and hold harmless the funeral establishment(s) and funeral director, their officers and employees from any liability, cost, expenses, or claims resulting from this authorization.

I request that following cremation, Bi-State Cremation & Funeral Service*

Return Cremains to legal agent

Return to any family member

Mail to:

I direct Bi-State Cremation to bury scatter or entomb cremains etc.

Name, postage address and phone number for cremains to be mailed:*

(Charges will apply for shipping)

Location*

I specifically agree that if the said cremains are left in the custody of Bi-State Cremation & Funeral Service for over 30 days, Bi-State Cremation & Funeral Service will make whatever disposition of the cremains it deems appropriate.

Implanted medical devices:
I understand and acknowledge that defibrillators, pacemakers, other implanted battery powered devices, radioactive implants, and certain prosthetics may create a hazardous condition when placed in a cremation chamber and subject to heat. I am providing Bi-State Cremation & Funeral Service and the crematory with regards to implanted medical devices:

Implanted Devices*

There are no mechanical devices

There is an implanted device, and I authorize Bi-State Cremation or the crematory to remove the device and dispose of it.

Authorization Agent Signature*

Authorized Agent Name*

First Last

Date*

Time*

Phone*

Email*

Authorized Agent Home Address*

Street Address City State / Province / Region ZIP / Postal Code Country

If known, please provide the last place of residence for the deceased

Comments

This field is for validation purposes and should be left unchanged.

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