Authorization - Jacqueline Morrison


NORTH CAROLINA BOARD OF FUNERAL SERVICE

STANDARD CREMATION AUTHORIZATION FORM

 

NOTICE: THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION.

THE PROCESS IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.

 

Name of Individual for which cremation is being arranged (“Decedent”): 

Date of Birth:   

Date of Death:   

Time of Death:   

Age:   

Place of Death:  

Hospice (Yes or No):   

Medical Examiner’s Authorization Required (Yes or No):   

Death Due to an Infectious Disease (Yes or No):   

Individual Confirming Identity of Decedent:   
(Typed or Printed Name)

 

A. The undersigned (hereinafter referred to as “Authorizing Agent{s}”) hereby certify, warrant, and represent that I/we have the full legal right and authority to authorize and arrange for the cremation and final disposition of (hereinafter referred to as “Decedent”);

Please select from the options below: 

 

1. Authorizing Agent(s) is (are) not aware of any living person who has a superior right to that of Authorizing Agent(s) as set forth in G.S. 90-210.124; or 

2. If there is another living person who does have a superior right to that of Authorizing Agent(s), Authorizing Agent(s) represent that Authorizing Agent(s) has (have) made all reasonable efforts to contact such person, has (have) been unable to do so, and has (have) no reason to believe that such person(s) would object to the cremation of Decedent.

Name(s) of person(s) attempted to be contacted (if applicable):


B.
 
If Authorizing Agent(s) is/are aware of any other living person(s) with equal right to that of Authorizing Agent(s), Authorizing Agent(s) hereby certify, warrant, and represent that Authorizing Agent(s) has (have) either:

Please select from the options below (if applicable):   

1. disclosed the location of all living persons with equal right to that of Authorizing Agent(s), as set forth in G.S. 90-210.124, or 

2. does (do) not know the location of any other living person with an equal right to that of Authorizing Agent(s).

C. If Decedent’s cremation involves a licensed funeral establishment or individual licensed pursuant to G.S. 90-210.25(a2)(2):

I / We hereby request and authorize: Blue Star Cremation

(hereinafter referred to as “Funeral Provider”) whose address is:

1130 N. Winstead Avenue, Rocky Mount, NC 27804

 to take possession of Decedent’s human remains and make arrangements for cremation at:

Wheeler &Woodlief Funeral Home and Cremation Services,

a crematory licensee (hereinafter referred to as “Crematory Licensee”) whose address is:

1130 N. Winstead Avenue, Rocky Mount, NC 27804

in accordance with and subject to: (a) the terms and conditions set forth in this Authorization; (b) any applicable state or local laws, rules, and regulations; and (c) the rules and regulations of said Funeral Provider and/or Crematory Licensee.

Acknowledgement: By initialing below, I/We hereby acknowledge each item set forth in Sections A through C above.

Initial: 

D. If Decedent’s cremation does not involve a funeral establishment or individual licensed pursuant to G.S. 90-210.25(a2)(2):

I/We hereby authorize:   

(hereinafter referred to as “Crematory Licensee”) whose address is:

 

 

to take possession Decedent’s human remains and make arrangements for cremation in accordance with and subject to: (a) the terms and conditions set forth in this Authorization; (b) any applicable state or local laws, rules, and regulations; and (c) the rules and regulations of said Crematory Licensee.

E. Unless specifically permitted by G.S. 90-210.129(h), cremation will be performed individually. Due to the nature of cremation, valuable materials may not be recoverable. In the event that there are such valuable items I/we wish to retain, it is my/our responsibility to remove them or have them removed from Decedent’s remains prior to cremation. Body prostheses, dental bridgework, or dental fillings within Decedent’s remains may either be destroyed or may not be recoverable. Accordingly, Authorizing Agent(s) represent and warrant to Crematory Licensee that such materials have been removed from Decedent’s remains or, if not, that they may be removed from Decedent’s remains and disposed of by Crematory Licensee or may be destroyed by cremation.

F. Cremation begins with the placement of the cremation container into the cremation chamber where it is subject to intense heat and flame reaching temperatures of 1400 to 1800 degrees Fahrenheit. I/We hereby authorize Crematory to cremate Decedent’s human remains. Following a cooling period, the cremated remains are then swept or raked from the cremation chamber. Cremated remains, depending on the bone structure of the decedent, will weigh approximately 4 to 8 pounds, and are usually white in color, but can be other colors due to temperature variations and other factors.

G. Cremated remains consist primarily of bone fragments, which are processed or pulverized to permit their placement in an initial container or other suitable container. I/We hereby authorize Crematory Licensee to process and/or pulverize Decedent’s cremated remains. Unless another container type is purchased for the cremated remains of Decedent, Crematory Licensee will place the cremated remains in an initial container that may not be recommended for any type of shipment. In the event the capacity of the initial container or any other container is insufficient to accommodate all of the cremated remains of Decedent, a separate initial container will be used and returned to the person(s) designated in Paragraph O of this Authorization.

H. Even with the exercise of reasonable care and the use of Crematory Licensee’s best efforts, it is not possible to recover all particles of the cremated remains of Decedent; some particles may inadvertently become commingled with particles of other cremated remains remaining in the cremation chamber and/or other devices utilized to process (pulverize) the cremated remains. I/we hereby authorize Crematory Licensee to dispose of any such residual particles in any lawful manner it deems appropriate.

I. Unless otherwise specifically approved for cremation or by the manufacturer or proper regulating agency, pacemakers or other mechanical devices may create a hazardous condition when placed in a cremation chamber. Crematory Licensee will not, therefore, cremate any human remains which contain any type of hazardous implanted mechanical device. In the event the remains of Decedent do contain such a device, Authorizing Agent(s) hereby authorize and instruct Funeral Provider or when not applicable, Crematory Licensee, its agents and employees to remove any and all hazardous mechanical devices from Decedent prior to the cremation process. Any such removal must be carried out in accordance to the manufacturer’s guidelines and any applicable law or rule.

TO THE BEST OF THE KNOWLEDGE OF AUTHORIZING AGENT(S), THE REMAINS OF DECEDENT

Please select from the options below:   

1. DO CONTAIN A PACEMAKER THAT IS NOT APPROVED FOR CREMATION BY THE PACEMAKER’S MANUFACTURER OR PROPER REGULATING AGENCY.

2. DO NOT CONTAIN A PACEMAKER THAT IS NOT APPROVED FOR CREMATION BY THE PACEMAKER’S MANUFACTURER OR PROPER REGULATING AGENCY.

AUTHORIZING AGENT(S) CERTIFY THAT TO THE BEST OF HIS/HER/THEIR KNOWLEDGE, THE REMAINS OF DECEDENT:

Please select from the options below: 

1. DO CONTAIN ANY TYPE OF HAZARDOUS IMPLANTED MECHANICAL DEVICE.

2. DO NOT CONTAIN ANY TYPE OF HAZARDOUS IMPLANTED MECHANICAL DEVICE.

Acknowledgement: By initialing below, I/We hereby acknowledge each item set forth in Sections D through I above.

Initial: 

J. Crematory Licensee reserves the right to reject a cremation container not suitable for cremation. Remains received in an unsuitable cremation container may be removed prior to cremation and placed in a suitable container; and Crematory Licensee reserves the right to dispose of such noncombustible container(s) at its sole discretion. Crematory Licensee is authorized to remove and discard handles or any other items attached to the cremation container which may cause damage to the cremation chamber.

K. If no final disposition is given, the cremated remains of Decedent will be held by Funeral Provider or if not applicable, Crematory Licensee, for 30 days before they are disposed of, unless the cremated remains of Decedent are received from Funeral Provider or if not applicable, Crematory Licensee, prior to that time, in person, by Authorizing Agent(s) or his/her/their designee.

L. I/We authorize Funeral Provider or if not applicable, Crematory Licensee, to return the cremated remains of Decedent according to my/our directive(s) below. I/We understand that the services and obligations of Crematory Licensee shall be fulfilled when the cremated remains of Decedent are returned to the possession and custody of Funeral Provider, if applicable. I/We hereby authorize Funeral Provider or if not applicable, Crematory Licensee, to arrange for the disposition of the cremated remains of Decedent as follows (complete appropriate disposition):

Please select an option below after filling out applicable fields: 

1. Deliver the cremated remains of Decedent to: cemetery, with which arrangements have already been made for the cremated remains of Decedent to be: .

2. Delivery of the cremated remains of Decedent to the US Postal Service for shipment via Registered, Return Receipt mail to:  whose address is:

 

.

3. Release the cremated remains of Decedent to the following designated person(s):

Name:   

Relationship:  

Name:  

Relationship:  

Name: 

Relationship:  

Name:   

Relationship:  

4. Other (Describe): 

M. Authorizing Agent(s) understand(s) that after this Standard Cremation Authorization Form is executed, Authorizing Agent(s) can only revoke the authorization and instruct Funeral Provider and/or Crematory Licensee to cancel the cremation and to release or deliver Decedent’s remains to another funeral provider and/or crematory licensee by providing such instructions to Crematory Licensee in writing prior to the commencement of cremation. Crematory Licensee shall honor these instructions provided that it receives such instructions prior to commencement of the cremation of Decedent’s human remains. 

Acknowledgement: By initialing below, I/We hereby acknowledge each item set forth in Sections J through M above.

Initial: 

N. Pursuant to G.S. 90-210.125(c), a crematory licensee shall have the legal right to cremate human remains upon the receipt of a cremation authorization form signed by an authorizing agent. There shall be no liability for a crematory licensee that cremates human remains pursuant to such authorization, or that releases or disposes of the cremated remains pursuant to such authorization, except for such crematory licensee’s gross negligence, provided that the crematory licensee performs such functions in compliance with the provisions of NC General Statutes Chapter 90, Article 13F. There shall be no liability for a funeral establishment or individual licensed pursuant to G.S. 90-210.25(a2)(2) or licensee thereof that causes a crematory licensee to cremate human remains pursuant to such authorization, except for gross negligence, provided that the funeral establishment or individual licensed pursuant to G.S. 90-210.25(a2)(2) and licensee thereof and crematory license perform their respective functions in compliance with the provisions of G.S. 90-210.125.

REPRESENTATIONS OF FUNERAL DIRECTOR / FUNERAL SERVICE LICENSEE (To be completed AT-NEED)
By executing this Standard Cremation Authorization Form as a funeral director or funeral service licensee and an agent / employee of Funeral Provider, I warrant to the best of my knowledge that (1) Funeral Provider was responsible for making arrangements with Authorizing Agent(s) for the cremation of Decedent and that I have reviewed this Standard Cremation Authorization Form with Authorizing Agent (s); (2) that no employee of Funeral Provider has any knowledge or information that would lead it to believe that any of the answers provided on this form, by Authorizing Agent(s), are incorrect; (3) that the human remains delivered to Crematory Licensee and represented as the human remains specified on this form are in fact the human remains that were identified to Funeral Provider as Decedent; and (4) that Funeral Provider obtained all necessary permits authorizing the cremation of Decedent, including approval from the Office of the Chief Medical Examiner, if required. I understand that failure to complete this Standard Cremation Authorization Form in its entirety and other required documentation will result in the delay of the cremation of Decedent.

Funeral Director or Funeral Service Licensee:  Kemp J. David

License No.  FSL 3066

Signature: /s/  Kemp J. David

Date of Signature:   August 28, 2020

REPRESENTATIONS OF CREMATORY LICENSEE (To be completed AT-NEED by crematory licensee when no funeral provider involved)
By executing this Standard Cremation Authorization Form as an agent / employee of Crematory Licensee, I warrant to the best of my knowledge that (1) Crematory Licensee was responsible for making arrangements with Authorizing Agent(s) for the cremation of Decedent and that I have reviewed this Standard Cremation Authorization Form with Authorizing Agent(s); (2) that no employee of Crematory Licensee has any knowledge or information that would lead it to believe that any of the answers provided on this form, by Authorizing Agent(s), are incorrect; and (3) that Crematory Licensee obtained all necessary permits authorizing the cremation of Decedent, including approval from the Office of the Chief Medical Examiner, if required. I understand that failure to complete this Standard Cremation Authorization Form in its entirety and other required documentation will result in the delay of the cremation of Decedent.

Representative of Crematory Licensee:   Kemp J. David

Signature: /s/  Kemp J. David

Date of Signature:   August 28, 2020

FOR CREMATORY LICENSEE USE ONLY
Cremation approved by:  Kemp J. David

Date:  August 28, 2020

Special Instructions:

SIGNATURE OF AUTHORIZING AGENT(S) FOR CREMATION OR AND FINAL DISPOSITION  
By executing this Standard Cremation Authorization Form, as Authorizing Agent(s), the undersigned warrant that all representations and statements, except for Sections C or D and Section I, if that information is unknown to Authorizing Agent(s), contained on this form are true and correct, that these statements were made to induce Crematory Licensee to cremate
the human remains of the Decedent, and that the undersigned have read and understand the provisions contained on this form.

Authorizing Agent (typed/printed name):   

Relationship to decedent:   

Phone number:   

Address:   

Date of signature:

Signature of Authorizing Agent:

Leave this empty:

Signature arrow
Blue Star Cremation https://bluestarcremation.com
Signature Certificate
Document name: Authorization - Jacqueline Morrison
lock iconUnique Document ID: c6eb09966256e156e4f79424b480dd057854b799
Timestamp Audit
August 28, 2020 11:43 am CDTAuthorization - Jacqueline Morrison Uploaded by Blue Star Identifications - [email protected] IP 75.110.83.219