DECLARATION FOR DISPOSITION OF CREMATED REMAINS

I/We hereby declare (my remains) or (the remains of) _____________________________ in 
                                                                                                                  
Name of Person Arrangements are for
the possession of ____________________________________________, will be cremated by
                                                                          Name of Funeral Establishment and Telephone Number
 
____________________________________________________________and shall be disposed of in the
                     Name of Crematory and Telephone Number

following manner (Notes 1):_________________________________________________________________
                                                                                                   Manner, Location and Other Details of Disposition
________________________________________________________________________________________

__________________________________________________________________________________

_________________________________________________________________________________________
                                                                                                                                                Attach additional pages if necessary


Name of person(s) with the legal right to control disposition (Note 2):__________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Signed _____________________________________________________________ Date ______________
                       Person (s) with legal right to control disposition or Self, if prearranging

Signed _____________________________________________________________ Date ______________
                       Person (s) with legal right to control disposition

Signed _____________________________________________________________ Date ______________
                       Person (s) with legal right to control disposition

Signed _____________________________________________________________ Date ______________
                       Person (s) with legal right to control disposition

Name of person(s) contracting for cremation services: _______________________________

__________________________________________________________________________

Signed ______________________________________________________________ Date______________
                      Person (s) contracting for cremation services

Signed
___________________________________________ Lic. # _____________ Date ______________
                     Funeral Director, Employee, or Agent for funeral establishment                                If funeral Director

Note 1: See Health & Safety Code Sections 7054, 7054.6, 7116, 7117 for legal dispositions of cremated remains.
Note 2: See Health & Safety Code Section 7100 for the list of person(s) with legal right to control disposition of human remains.

IMPORTANT: Business and Professions Code 7685.2(b) requires Funeral Establishment to complete this form, provided by the Cemetery and Funeral Bureau, when making arrangements for cremation. Failure to complete this form may result in disciplinary action by the Bureau. This declaration does not replace the written authorization to cremate required by Health and Safety Code Sections 7110 and 7111.

California Department of Consumer Affairs, Cemetery and Funeral Bureau  www.deca.ca.gov/cemetery (Rev 3/2003)
STATE OF CALIFORNIA - STATE AND CONSUMER SERVICES CEMETERY AND FUNERAL BUREAU
1625 North Market Blvd., Suite S-208, Sacramento, CA 95834  -  916-574-7870