Cremation Society of Los Angeles
6427 So. Eastern Avenue
Bell Gardens, California  90201
License # FD 1694


To:    CREMATION SOCIETY OF LOS ANGELES                   License # FD 1694
RE: _______________________________________(Decedent) I,___________________________________
                   Name of Deceased                                                                                        Your Name

[   ] Do   [   ] Do Not    (check one)  request embalming, which I understand is the addition to, or the replacement of, 
body fluids by chemical preservations or the application of chemical preservations for the temporary preservation
of the body.   I understand that embalming is not required by law.

I understand that for storage or embalming purposes the decedent may be transported to the following licensed 
funeral establishment:__________________________________________  then returned for funeral services.  
 I understand I may be charged an additional fee for transport.

The undersigned hereby represents that he/she has legal right to control disposition of the remains of the decedent.

Executed this ________________day of________________, year of __________at_______________, California
                                    Date                                 Month                             Year              Your Location

                        Signature                                                              Relationship to Deceased

Below this line is to be completed by the funeral establishment if Authorization to Embalm and Notification to Transport is obtained orally (By Telephone)

The above statement of authorization and notification was read to: ______________________________________

Relationship _____________________ who  [  ] Did    [  ]  Did Not (check one) authorize embalming
at the above funeral establishment.

Phone ________________________________ Date and time authorization granted ________________________

Signature of funeral establishment representative accepting authorization.

I declare under penalty of perjury that the foregoing is true and correct.

Executed this ___________ day of _________, year of _________ at __________________, California

(s) __________________________________________________________________________________