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ROSEHILL CREMATION AUTHORIZATION
(PLEASE PRINT OR TYPE)
REG. NUMBER
CREMATION DATE
TIME OF CREMATION
NAME OF DECEASED
AGE
ADDRESS
CITY
STATE
CAUSE OF DEATH
TIME OF DEATH
DATE OF DEATH
PLACE OF DEATH
DEATH DUE TO INFECTIOUS/
CONTAGIOUS DISEASE
PACEMAKER
RADIOACTIVE IMPLANT/
TREATMENT
VETERAN
DISPOSITION OF CREMATED REMAINS
ROSEDALE/ROSEHILL

SIGNATURE
SIGNATURE
LOCATION
DATE
FOR CREMATORY USE
REG. MAIL #
DATE SENT
SCATTERING:
PAGE #
PAGE #
PAGE #
PRIORITY MAIL EXPRESS TO: OR PICK UP BY:
1. FUNERAL DIRECTOR
2. AUTHORIZING AGENT
3. OTHER (Complete Below)
NAME (TYPE OR PRINT)
ADDRESS
CITY
STATE
ZIP CODE
PHONE: ()
I CERTIFY THAT I HAVE FULL POWER AND AUTHORITY TO ARRANGE FOR THE CREMATION AND DISPOSITION OF THE DECEASED. ALL NON-COMBUSTIBLE MATERIALS DELIVERED WITH THE HUMAN REMAINS WILL BE DISPOSED OF BY THE COMPANY. I HEREBY AGREE TO INDEMNIFY AND KEEP HARMLESS THE ROSEHILL CEMETERY ASSOCIATION AND ITS REPRESENTATIVES FOR AND FROM ALL LIABILITY DUE TO SAID AUTHORIZATION, CREMATION AND DISPOSITION OF THE CREMATED REMAINS AS STATED ON THE REVERSE SIDE.
NAME (PRINT OR TYPE)
RELATIONSHIP
X
SIGNATURE
ADDRESS
CITY
STATE
ZIP CODE
IMPORTANT!  —  DISPOSITION OF CREMATED REMAINS
THE CREMATION PROCESS IS BY NO MEANS "FINAL." DISPOSITION AND MEMORIALIZATION OF CREMATED REMAINS THROUGH AN APPROPRIATE MEMORIAL LOCATION SHOULD BE COMPLETED AT THE SAME TIME AS FUNERAL ARRANGEMENTS.
ENTER HERE PROPOSED DISPOSITION OF CREMATED REMAINS:
I CERTIFY THAT THE FOREGOING AUTHORITY AND CERTIFICATE ARE JUST AND TRUE TO THE BEST OF MY KNOWLEDGE:
FUNERAL HOME (TYPE OR PRINT)
FUNERAL DIRECTOR SIGNATURE
LIC. #
ADDRESS
CITY
STATE
ZIP CODE
DATE
FOR CREMATORY USE—CREMATED REMAINS RECEIVED BY:
NAME (PRINT OR TYPE)
SIGNATURE
ADDRESS
DATE
DR. LIC. #
RR-1000R11 (9-98)