Release Authorization Form

"*" indicates required fields

Name of Deceased:*

I authorize the release and removal of the remains to said funeral establishment for the purpose of:*

Embalming

Cremation

I represent that I am the next of kin, or am acting as an authorized agent for the next of kin.*

True

False

Your Name*

Date

Relationship to Deceased:*

Email:*

Phone:*

Address*

Street Address City State ZIP Code

Date of Birth:

Last 4 Digits of S.S.N.:

State ID Type:

Registered In:

State

ID Number:

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