Evergreen Cemetery
204 North Evergreen Avenue
Los Angeles, California 90033
 

 

Cremation
Authorization
And
Declaration

 

For more information on Cemetery and Cremation matters, Contact:
Department of Consumer Affairs Cemetery and Funeral Bureau
1625 North Market Blvd., Suite S-208, Sacramento, CA 95834  -  916-574-7870

 

                         Declaration of Facts by Authorizing Agent(s)
(In This document the word "I" sall refer to all persons authorzing the cremation & disposition.)  I, the undersigned declarant(s) do hereby warrant that I am the person(s) having full legal authority to authorize the cremation and disposition of ___________________ my ________, whose last know address was ______________________________________, ______________________, ________, _______ and who died on ________, I further state that I am Section 7100 authority pursuant to the following.
____________________________________________________________________________________
Section 7100 Authority ...

I am the Section 7100 authority legally authorized to permit/select cremation as the form of disposition for the decedent listed herein.  My authority is because I am one of the following:
Initial one box.


____ Self. I am signing this as a result of a preneed contract I have entered into.

____ Attorney in fact under a power of attorney for health care.  Attach copy.

____ Surviving Spouse.

____ Registered domestic partner.

____ We (insert #) ____ adult children represent a majority  of of (insert #) ____ adult children.  We are not aware of any opposition to the cremation of the decedent on the part or one half or more of said adult children.

____ We are the available surviving adult children of the deceased and have used reasonable efforts to notify all other surviving adult children of this authorization and are not aware of any opposition of the cremation of the decedent on the part of one half or more.

____ Surviving competent parent(s) of the decedent.  No adult children exists.

____ Other: A competent adult person(s) in the next degree of kindred.  I am the only surviving adult ______________ and declare that no other person(s) listed above exists or I have used reasonable efforts to notify such person(s) and have been unsuccessful.  Or we are the majority of the surviving ___________________ and we have used reasonable efforts to notify all other persons in the same degree of kindred and are not aware of any opposition to this authorization by one half or more.

   

____ I am a licensed funeral director.  My license # is _____________ and I have notified the public administrator, in writing, of the passing and that there are no know persons with the authority to sign the authorization.  The public administrator has failed to act and seven days have elapsed from the date of notification; therefore I am acting as the authorizing agent.

I make this declaration to induce you to cremate the above named decedent and agree to hold you harmless from any claims which may result from the use of this declaration.

Signed __________________________________________

Print ____________________________________________

Relationship ________________________ Date _________

Signed __________________________________________

Print ____________________________________________

Relationship ________________________ Date _________

Signed __________________________________________

Print ____________________________________________

Relationship ________________________ Date _________

Signed __________________________________________

Print ____________________________________________

Relationship ________________________ Date _________

 

 

Authorization for Cremation & Disposition

I do hereby give this explicit authorization to: Evergreen Cemetery/Crematory (the crematory) to provide the following services, to which I agree to pay the usual and customary fees.

1. Cremation:
Cremated the body of the decedent named above in accordance with the subject to the crematory's rules and regulations and the law and regulation of the Sate of California.
I acknowledge the following descriptive statement of the cremation process as required by the Health & Safety code Section 7054.7 (c) (b).
"The human body burns with the casket, container, or other material in the cremation camber.  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 commingled with the cremated remain.  nearly all of the content 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 crack and uneven places in the chamber.  periodically, the accumulation of this residue is removed and interred in a dedicated cemetery, or scattered at sea."

1a. I understand that the crematory will not accept the remains of the Decedent for cremation unless they are in a leak resistant, rigid combustible container.  I authorize the crematory to remove and dispose of handles, ornaments and all other non combustible maerials of the cremation container or casket.

1b. I further acknowledge the following: "A person having the right to control disposition of cremated remains may remove the remains in a durable container from the place of cremation or interment, pursuant to Section 7054.6 of the Health & Safety Code." If the cremated remains container cannot accommodate all of the cremated remains of the deceased, the crematory shall provide a larger container at no additional cost, or place the excess in a second container that cannot easily come apart from the first, pursuant to Section 8345 of the Health & Safety code.

2. Implants, Mechanical & Radioactive Devices:
Mechanical or radioactive devices, such as pace makers and insulin pumps may be a hazard if placed in the cremation chamber.  The crematory will therefore not knowingly cremate any remains which contain such a device.

I certify that the remains of the Decedent do not contain a mechanical device or that I have arranged for their removal prior to delivery to the crematory. ________INITIALS

3. Mementos, Jewelry, Dental Appliances/Gold-Silver, & Other Foreign Materials
Items such as personal mementos, jewelry, dental appliances or dental gold/silver, prostheses and any other foreign materials paced in the cremation chamber with the decedent and cremated will either be destroyed or rendered unrecognizable.  If any such items are recovered form the chamber I authorize their disposal.

4. Disposition:
I authorize you to take the action I have indicated below with respect to the decedent's cremated remains.
_____ Deliver/Release remains to: ________________________________________________________________
                                                                                          
Name & Address
           For the following disposition _______________________________________________________________

_____ Mail the remains to: ______________________________________________ Via U.S. Postal-Registered Mail

_____ Other __________________________________________________________________________________
Note: Cremated remains not picked up within 90 days of the decedents death at the crematory may be delivered to a licensed crematory for disposition, in a manner which may make the remains non-recoverable.  If the remains are mailed, I agree that the crematory is acting solely as my agent in mailing the remains, and agree that the crematory shall not be liable if the remains are lost or damaged. ______INITIALS.

Authority to Conduct Burial or Cremation Service

This is your guide to correctly selecting  your authority in authorizing the cremation or burial of your family member.  Please read these instruction carefully as incorrect designation agents cannot authorize our services.

Declaration: I declare that I am the person having full legal authority to authorize the ____ burial or ____ cremation of __________________________ (Decedent).
I warrant that my authority is because I am the following (checked agent:

_____ Self (This designation is only when a Pre-Need Contract is signed.

_____ Attorney in fact under a Power of Attorney for Health Care.
Attach a copy of the Power of Attorney for Health Care.  A General Power of Attorney is not acceptable Unless it specifically authorizes disposition.

_____ The surviving spouse or Registered Domestic Partner.

_____ I am the sole surviving Adult child of the deceased.

_____ We (insert #) ______ adult children, represent a majority of (insert #) _____ adult children. All adult (over 18 years old) children must sign the authorization.  We are not aware of any opposition to the burial or cremation of the decedent on the part of one half or more of said adult children.

_____ We are the available surviving adult children of the deceased and have used reasonable efforts to notify all other surviving adult children of this authorization and are not aware of any opposition to the burial or cremation of the decedent on the part of one half or more of said adult children.

_____ Surviving competent parent(s) of the decedent.  No adult children exist.

_____ Other: A competent adult person(s) in the next degree of kindred.
I am the only surviving ___________________________ and declare that no other person(s) listed above exists or I have used reasonable efforts to notify such person(s) and have been unsuccessful. (OR) We are the majority of the surviving __________________________ and we have used reasonable efforts to notify all other persons in the same degree of kindred and are not aware of any opposition to this authorization by one half or more.

_____ I am a licensed Funeral Director, License # ____________ and have notified the Public Administrator, in writing, of the decedent's passing and that there are no known persons with the authority to sign the authorization. The Public Administrator has failed to act and seven days have elapsed from the date of notification; therefore, I am acting as the authorizing agent.

Executed at _________________________, California, this _____ day of ______________, 20_____

Signature ____________________________________________ Relationship: _________________________

Signature ____________________________________________ Relationship: _________________________

Signature ____________________________________________ Relationship: _________________________