1. The information, statements, and instructions set out on the front of this Cremation Authorization are completely a11d accurate.
2. I have the necessary authority under applicable Missouri law to direct the cremation of the Decedent’s remains and the disposition of the Decedent’s cremains pursuant to the instructions set out in this Cremation Authorization.
3. Unless stated otherwise in Disclosure of Pacemaker or Radioactive Implants, I have no reason to believe the Decedent’s body contains any implanted medical device.
4. I have communicated my Intent to direct the cremation of the Decedent’s remains to any persons who are of closer blood relation to the Decedent than myself n.
5. I have no knowledge of any objection”‘* to the cremation of the Decedent’s remains as the method for final disposition, or to my instructions for the delivery of Decedent’s cremains.
6. I authorize Ozark Memorial Park Crematory to take possession of the Decedent pursuant to the provisions set forth in this Cremation Authorization.
7. I am responsible for all charges and expenses incurred with respect to this Cremation Authorization.
8. I understand that cremation is accomplished by placing the Decedent’s body in a casket or alternative container and introducing these into the crematory retort. The temperature in this retort is raised to the point of combustion. After approximately two hours, all substances are oxidized away with the exception of calcified bone fragments, and any metal which may be present. After a short cooling period, the cremated remains are brushed from the inside of the retort with a steel bristled broom. Any foreign matter is removed. The cremated remains are then processed to a power-sand like consistency. They are placed into either a temporary container, or a permanent cremation um, and delivered to the person identified in this Cremation Authorization form. Due to the nature of the cremation process, any valuable material, including dental gold, will either be destroyed or not be recoverable. Anything other than the cremated remains will be destroyed by the Crematory. If the container or any portion thereof, is not suitable for cremation, the Crematory may require the remains to be removed to a suitable container. The cremated remains will include bone fragments that will be reduced in size and placed in an urn. In the likely event that the amount of cremated remains should exceed the capacity of the um selected, Crematory is hereby authorized to return said excess cremated remains in a temporary container.
9. I indemnify and hold harmless the Crematory, and its members, representatives, and employees from any liability, costs, expenses, or claims resulting from actions taken in reliance on this Cremation Authorization form. 10. Cremation will take place after any scheduled ceremonies or viewing has been completed, civil and medical authorities have issued all required permits, all necessary authorizations have been obtained, no objections have been raised, and at least 48 hours have passed since the medical examiner’s statement of the time of death, provided the Crematory is authorized to perform the cremation according to its own time schedule, as work permits, without obtaining any further authorization or instructions.
10. If Decedent’s cremains is not claimed pursuant to the Declaration of Intent within 30 days of the cremation, Crematory is authorized to deliver Decedent’s cremains to me at the address set out above, by any method determined by Crematory to be reasonable. Upon release of Decedent’s cremains to the entity or person identified in the Declaration of Intent, or the deposit of Decedent’s cremains with registered postal service (or by overnight delivery service), I hereby release Crematory from claims for dan1ages. In the event Decedent’s cremains is not claimed, or can not be delivered to me, within 30 days from the date of cremation, the Crematory shall be authorized to either scatter the cremains in Ozark Memorial Park Cemetery’s scatter garden or to place the cremated remains in long term storage and will be responsible for all charges incurred with regard to such storage and any eventual disposition of decedents remains pursuant to Missouri law.
The cremation process was initiated on what date (XX-XX-XXXX)
The cremation process was initiated at what time? AM or PM
Cremains were released to: (Name)
Relationship to Deceased:
Address of the Delivery
If delivery of cremains by shipment, the delivery company and shipping/receipt number:
Date the Cremains were released:
If delivery of cremains by means other than an employee of a Missouri licensed funeral establishment, the name and means of delivery:
*Kansas funeral establishments must provide a copy of the coroner’s permit. **This certification is not required of a surviving spouse or a parent with custodial rights if the Decedent was a minor. In the absence of the appropriate written directive from the decedent, certain members of the Decedent’s family are afforded a priority to direct the disposition or the Decedent’s remains if the family member(s) assumes responsibility for the disposition. If the person directing the cremation is not related by blood or is a sibling or a more distant relative, notice must be given to any living parent, adult children, or siblings of the Decedent.
Deceased’s Last Residence
Location Where Death Occurred
Name of Deceased
Deceased’s Place of Birth
Funeral home delivering the remains
Funeral Director (arranging)
Date of Death
Time of Day
Date and Place of the Funeral:
Person authorizing cremation
Relationship to the Deceased
Must be the same person who signs this form and made the arrangements with the funeral home or crematory)
Will the body be embalmed at time of delivery to the Crematory?
Will there be a viewing at the Crematory?
If yes, what date and time?
Did the decedent have an infectious, contagious or communicable disease? If yes, please list below.
If yes, please list below:
Mechanical, radioactive devices or implants in the Decedent create a hazardous condition when placed in a cremation chamber. All pacemakers must be removed by the funeral home and radioactive implants must be removed by a physician prior to delivery of the decedent to the crematory.
Do the Decedent’s remains contain any such devices?
If yes, do you certify that these devices have been removed?
Has the deceased been treated with therapeutic radionuclide?
If yes, when was the treatment last administered?
State whether all valuables have been removed from Decedent’s body, and if not, itemize the valuables to be returned to Funeral Home Staff Member delivering the body for cremation
Is the interment oft he cremains scheduled to be made at Ozark Memorial Park, and if not, designate the location of interment or scattering if known:
If no, list valuables:
The crematory is authorized to deliver the decedent cremains in the following manner:
DISCLOSURES. WARRANTIES AND PERMISSlONS (INITIAL EACH)
Separate authorization(s), if necessary, shall be attached to, and considered part of, this form.
I certify that the deceased person named above has not given other specific directions concerning the disposal of his/her remains that conflict with cremation
I the undersigned, hereby certify that I am the closest living next of kin of the Decedent as defined by RSMo Section 194.119. All other individuals comprising Decedent’s closest next of kin have declined responsibility for the disposition of Decedent’s remains and I have assumed such responsibility
By signing this form, Authorizing Agent agrees and certifies to Ozark Memorial Park Crematory that the front of this form has been completed accurately and that he/she has read the Certifications and Agreements set out on Page 2.
AM / PM
Signature of Authorizing Agent
Witness Print Name