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


                AUTHORIZATION FOR DISPOSITION WITH OR WITHOUT EMBALMING

To:    CREMATION SOCIETY OF LOS ANGELES                   License # FD 1694
         
                                                                                                  
RE: _________________________________________(Decedent) I,___________________________________

[   ] 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

________________________________________________________________________________________
                        Signature                                                              Relationship to Deceased