NOTICE:  This is a legal document.  It contains important provisions concerning cremation.  
Cremation is irreversible and final.  Read this document carefully before signing.
To:  Cremation Society of Los Angeles _________________________________(Provider/s)  
The undersigned hereby certify and represent that they are the legal custodian (s), having full legal authority 
to authorize the cremation, processing and disposition of the named decedent, and hereby request and authorize,
 Providers to make removal, take possession of,
make arrangements for and to cause the cremation, processing 
and disposition of the remains of:

1.  Name of decedent: Name of decedent: Name of decedent:_____________________________________
in accordance with and subject to the terms and conditions set forth in this Authorization, the Provider's rules 
and regulations and any applicable state or local laws, rules or regulations.  I/we agree jointly and severally to 
hold the Provider, its officers, agents, employees and the below named funeral director, harmless from any and 
all loss, costs, or damages it or they may suffer or incur by reason of acting upon this authorization and order.

I/we the undersigned understand and acknowledge that due to the nature of the cremation process, the entire 
amount of fragment remaining MAY not be included in the urn or container selected and that valuable material,
 including dental gold will either be destroyed or not be recoverable.  (See disclosure)

2. I/We the undersigned further State: (Must choose one)
[   ]  The decedent has no implanted device or prosthesis
[   ]  The decedent has an implanted device or prosthesis and I/we authorize and order removal 
and disposition of same prior to cremation, if necessary
Describe device: __________________________________________ [  ] Heart pacemaker    
Implanted mechanical devices may create a hazardous condition when placed in a cremation chamber.  I/we the undersigned agree
 that in the event of failure to notify the funeral director or Provider or others responsible for the removal of such a device, that 
the undersigned will be liable for any damages to the crematorium and/or injury to crematorium personnel.

3Disposition of Cremated remains  (Must choose one)
I/we the undersigned hereby order the disposition of the cremated remains as follows:        
[  ]  Burial at sea ________________________________
[  ]  Burial in Cemetery ___________________________________________________
[  ]  Release to Family ____________________________________________________   
[  ]   Special handling    ___________________________________________________ 
In the event that I have not called for the cremated remains as agree, or directed the final disposition within 30 days of cremation, 
disposition can be made at the discretion of the Provider/s.  I release any liability for this performance and I assume responsibility 
for the cost of the final disposition.  

DISCLOSUR (required by California State Law Cremation Standards Act January 1, 1994)  The human body burns with the
 casket, container, or other material in the cremation chamber.  Some bone fragments are not combustible at the incineration
 temperature and, as a result, remain in the cremation chamber.  During the cremation, the contents of the chamber may be moved 
to facilitate incineration.   The chamber is composed of ceramic or other material which disintegrates slightly during each cremation 
and the product of that disintegration is co-mingled with the cremated remains.  Nearly all the contents of the cremation chamber, 
consisting of the cremated remains, disintegrated chamber material and small amounts of residue from previous cremations are 
removed  together and crushed, pulverized or ground to facilitate inurnment or scattering.   Some residue remains in the cracks 
and uneven places of the chamber.  Periodically, the accumulation of this residue is removed and interred in a dedicated cemetery
property or scattered at sea. 
I/we have read the foregoing disclosure:
4.   SIGNATURE of person (s) authorizing cremation and disposition.   Date_____________

Signature ___________________________   



I hereby confirm my attention to an Identification viewing of the deceased.
I do*_________
            I do not ________    
Initial                                             Initial
wish to view the deceased prior to the cremation.
*(Additional charges may apply)
City, State, Zip ________________________________________________________________