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Name of Person to be Cremated

First Name
Middle (optional)
Last Name

Next of Kin

First Name:
Middle Name: (optional)
Last Name:
Phone Number:
Relationship to the deceased:
Home Address:
Home Address #2: (optional)
Home City:
Home State:
Home Zip:
E-mail Address:

Witness

First Name:
Last Name:
Phone Number:
Relationship to the deceased:
Home Address:
Home Address 2: (optional)
Home City:
Home State:
Home Zip:
Email Address:
   
Ship or Release To:
(Name of Individual to receive Cremation Remains) Mailing Address City St/Zip
(#1 is delivery of cremated remains via USPS, Registered Return Receipt Mail. Authorizing Agent agrees to assume all liability that may arise from such shipment, and to indemnify and hold the Crematory and Funeral Home harmless from any and all claims related to shipment.)

Note: All fields are required unless otherwise marked.

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