An Affordable Choice
1189 B Oddstad Drive Redwood City, CA 94063 Phone: 877-938-0672 Fax: 877-867-1436
The forms listed below are required by the State of California to authorize cremation. Fill in and check the forms thoroughly, sign, initial, and fax to A Direct Cremation. If your .pdf software has the ability to save filled in information, the forms can be emailed to email@example.com. You can also fill in, print, scan, and email the forms.
Including Fax Cover: ____ Pages
Disclaimer: This message is intended only for the use of the individual or entity to which it is addressed and may contain information which is privileged, confidential, proprietary, or exempt from disclosure under applicable law. If you are not the intended recipient or the person responsible for delivering the message to the intended recipient, you are strictly prohibited from disclosing, distributing, copying, or in any way using this message. If you have received this communication in error, please notify the sender and destroy and delete any copies you may have received.
aDirectCremation.com has been established for those families that are in need of services but may have special circumstances that prevent them for choosing a more traditional route. In order to serve our families in the most efficient and cost effective way possible we have established several requirements. Please see our guidelines below.
The California Health and Safety Code lists the persons who have the right to make decisions about disposition arrangements after an individual’s death unless other written instructions are left. They are listed in the following order:
All persons must be competent. And, except for spouses and parents, all persons must be at least 18 years of age. Domestic partners must be registered with the California Secretary of State. Decedent’s wishes must comply with the Health and Safety Code Section 7100.1 in order to be binding.
PLEASE PRINT LEGIBLY BELOW In the boxes below, fill in the required information which will be used to file the death certificate, which we plan to order for you based on your request. If any box is left blank, we will assume it is unknown and follow the guidelines of the State’s electronic death registry system.
The funeral establishment, aDirectCremation.com, (funeral establishment name)
defined below, made by or on behalf of . (name of decedent) license number FD 2036 , DOES DOES NOT X (check one) have a preneed arrangement, as If the funeral establishment does have a preneed agreement, complete the following: In compliance with Business and Professions Code Section 7745, the funeral establishment has presented to the person named below a copy of any preneed agreement which has been signed and paid for in full, or in part by, or on behalf of the deceased and is in the possession of the funeral establishment. Funeral Home Staff to Sign ADirectCreamtion.com “Preneed arrangement,” “preneed agreement” or “preneed” is written instruction regarding goods or services or both goods and services for final disposition of human remains when the goods or services are not provided until the time of death, and may be either unfunded or paid for in advance of need. Funeral Establishment’s Responsibility – Business and Professions Code Section 7745 requires a funeral establishment to present to the survivor of the decedent or the responsible party a copy of any preneed agreement in its possession which has been signed and paid for in full, or in part by, or on behalf of the deceased. Business and Professions Code Section 7685.6 requires a copy of any preneed arrangements to be disclosed prior to drafting any contract for funeral goods or services. The funeral establishment may present the copy in person, by certified mail, or by facsimile transmission, as agreed upon by the person with the right to control disposition. A funeral establishment that knowingly fails to present a preneed agreement as required is liable for a civil fine equal to three times the cost of the preneed agreement, or one thousand dollars ($1,000), whichever is greater. You may contact the Cemetery and Funeral Bureau for more information on funeral, cemetery or cremation matters or to file a complaint against a licensee: Cemetery and Funeral Bureau 1625 North Market Blvd., Suite S-208 Sacramento, CA 95834 916-574-7870
Signature of the survivor or responsible party
Print name of the survivor or responsible party
Signature of funeral establishment representative
Print name of funeral establishment representative
The funeral establishment must: Give a copy of the completed statement to the survivor or responsible party. Retain the original or a copy of the completed disclosure statement on file for not less than one (1) year after the preneed account has been audited by the Bureau or seven (7) years from the date the disclosure statement was made, whichever comes first.
Regarding: , decedent
I hereby certify as signed below, that in accordance with the wishes and majority approval of all others so authorized by SS.7100 of the California Health and Safety Code, I have the right to control the disposition of the above named decedent. I direct that the remains of the above named decedent be released or delivered without delay to aDirectCremation.com or their agent on request.
have any radioactive isotopes or pacemaker.
All valuables and/or personal property of the decedent are to remain at the place of death until further notice unless I specifically authorize otherwise in writing.
Signature: | Date:
Relationship: | Telephone:
Drivers License or I.D.#:
I hereby agree to hold aDirectCremation.com. harmless and to indemnify it or it’s assignees and/or agents from any and all claims, demands or damages which may be made or declared by reason of their acting according to this authorization.
Decedent Located at:
Identification Color: GREY
Embalming is the addition to, or the replacement of, body fluids by chemical preservatives or the application of chemical preservatives for the temporary preservation of the body. I understand that embalming is not required by law.
I understand that for storage or embalming purposes the decedent may be transported to the following locations:
The undersigned hereby represents that he/she has the legal right to control disposition of the remains of the decedent.
Relationship: | Executed this , at .
This section is to be completed by the funeral establishment if authorization to accept or decline embalming is obtained orally. The above statement regarding embalming and storage was read and/or provided to , Relationship:
authorize embalming at the above named funeral establishment. Phone: .
Date and time authorization granted:
This section is to be completed by the funeral establishment representative who is executing this authorization to accept or decline embalming. I declare under penalty of perjury that the foregoing is true and correct.
Executed this , at .
DECLARATION FOR DISPOSITION OF CREMATED REMAINS
I/We hereby declare (my remains) or (the remains of)_______________________________ in Name of Person Arrangements are forName of person(s) contracting for cremation services: ________________________________ ___________________________________________________________________________ the possession of aDirectCremation.com, 877-938-0672 the possession of aDirectCremation.com, 877-938-0672 , will be cremated by Name of Funeral Establishment and Telephone Number A Bay Area Crematory Inc., 209-938-0673 and shall be disposed of in the following manner (Note 1):________________________________________________________ Manner, Location and Other Details of Disposition ___________________________________________________________________________ ___________________________________________________________________________ Name of Crematory and Telephone Number ___________________________________________________________________________ Name and Address of Residence or Cemetery of where Cremated Remains are going OR County where remains are to be Scattered at Sea, must match # 40 on page 1 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
Signed ______________________________________________ Date _______________ Person(s) with legal right to control disposition
Signed ______________________________________________ Date _______________ Person(s) with legal right to control disposition Person(s) with legal right to control disposition or Self, if prearranging Signed Date / / 2018
Signed Date / /2018 Employee, or Agent for Funeral Establishment if Funeral Director Person contracting for cremation services Signed Lic.# Date / /2018
Note 1: See Health & Safety Code Sections 7054, 7054.6, 7116, 7117 for legal dispositions of cremated remains. Note 2: See Health & Safety Code Sections 7100 for the list of person(s) with the legal right to control disposition of human remains. IMPORTANT: Business and Professions Code § 7685.2(b) requires Funeral Establishments 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 the Health and Safety Code Sections 7110 and 7111.
NOTICE REGARDING CREMATED REMAINS 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 and Safety Code. If the cremated remains container cannot accommodate all cremated remains of the deceased, the crematory shall provide a larger cremated remains 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 and Safety Code. California Department of Consumer Affairs, Cemetery and Funeral Bureau www.dca.ca.gov/cemetery.
License # CR 273
A Bay Area Crematory Inc. www.abayareacrematory.com 2449 Station Drive, Stockton, CA 95215 (209) 938-0673 FAX (209) 205-9143 firstname.lastname@example.org Cremation Authorization Page 1 of 2 I, the undersigned, do hereby request and authorize A Bay Area Crematory Inc. or it’s agents (hereafter referred to as the Crematory), in accordance with and subject to its rules and regulations, to cremate or cause to cremate the remains said to be:
DEC: | Address:
“The human body burns with the casket, container, or other material in the cremation chamber. Some bone fragments are not combustible at the incineration temperature and, as a result, remain in the cremation chamber. 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 remains. Nearly all of the contents 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. (Section 7054.1 Calif. Health and Safety Code) Some residue remains in the cracks and uneven places of the chamber. Periodically, the accumulation of this residue is removed and interred in a dedicated cemetery property, or scattered at sea.” I certify that I am the next of kin or person authorized pursuant to Section 7100, Health and Safety Code, State of California, or I am a relative acting as the duly appointed agent for the next of kin, and it is my legal right and duty to control the disposition of the said remains of the above named deceased initial When cremating, the crematory will exercise reasonable efforts in keeping cremated remains separate. However, because it is impossible to guarantee or warrant that some bone particles or residue of one cremation could not possibly be mixed with those of another cremation, inadvertent or incidental commingling of cremated remains can occur. I specifically acknowledge the cremation process described and give express permission for the cremation to take place including incidental or inadvertent commingling of the remains with the residue of prior cremations and cremations taking place in the future (Section 7054.7 Calif. Health and Safety Code). initial The undersigned hereby acknowledges and understands that due to the nature of the cremation process, any valuable material, including but not limited to any jewelry or tooth fillings, will be either destroyed or not be recoverable and that any metal used in the construction of the casket or cremation container or from any type of prosthesis will be discarded, However, portions of such material can also be inadvertently commingled with the cremated remains. And the undersigned further certifies that any items that are desired to be saved and not cremated, will be removed and secured by the undersigned prior to the cremation taking place. initial If the cremated remains container cannot accommodate all cremated remains of the deceased, the crematory shall provide a larger cremated remains 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 and Safety Code.
The undersigned further understands and agrees that if no arrangements for the final disposition, release or transfer of the cremated remains in part or in whole is specified on this form, and if the Crematory is not subsequently provided with instructions concerning the final disposition, release or transfer of the cremated remains within thirty days of the date the cremated remains are available, the crematory shall be authorized to arrange for final disposition in any manner as authorized by law or by scattering at sea at a reasonable cost for which the undersigned will insure prompt payment, and in the event the crematory disposes of the cremated remains it is hereby understood and agreed that they will be nonrecoverable. The Crematory is further authorized to act as the agent for the undersigned for any and all instruments in connection with said authorizations, delivery or shipment. The undersigned understands that the services of the crematory will have been fully completed when the cremated remains are delivered or released to the Postal Service, Common Carrier, Person or Entity for transportation or final disposition, including but not limited to scattering, that further handling is the responsibility of the Postal Service, Common Carrier, Person or Entity. The Crematory is only acting as an agent for accommodation in carrying out these instructions and will be held harmless in the discharge of such accommodations. If the deceased has received any therapeutic radionuclide’s, radiation implants, heart pacemaker implants or any other life sustaining device that could be radioactive or explosive, it is specifically indicated below. If such devices do exist, the funeral director or others are instructed to remove by surgical procedure and properly dispose of it before cremation. In the event the undersigned fails to notify the funeral director or any others responsible for the removal of such devices, either radioactive or explosive, or any additional precautionary procedures that may be indicated, the undersigned will be liable for all disposal charges and costs of such material and any damage to the crematorium or injury to personnel. The deceased does does not have a pacemaker or radioactive implants.
License # CR 273
A Bay Area Crematory Inc. www.abayareacrematory.com 2449 Station Drive, Stockton, CA 95215 (209) 938-0673 FAX (888) 381-6220 email@example.com Cremation Authorization Page 2 of 2
The undersigned declares under penalty of perjury that all statements made on this form are true and correct and are made to induce the crematory to cremate or cause to cremate the said remains of the above named deceased. This is an ultimate and irreversible authority to make disposition of the remains as indicated and the undersigned shall assume full responsibility for the identity whether or not an election to view the remains has been made. The following covenants are hereby expressly indicated and acknowledged by the undersigned: ●Identification/Viewing (I.D. VIEW): Viewing of the deceased prior to cremation may be requested via your funeral director. Viewing of the deceased may take place at the crematory when it is arranged. ●Identification/Viewing of the remains prior to the cremation will will not take place. If viewing of the _ deceased will take place, indicate Date/Time__________________ and location___________________________________Estimate of Deceased Height_________________ Weight___________________ A deceased may be considered “oversize” and additional charges may be applied if any special handling is necessary: as in a larger casket/alternative container, when additional personnel or special equipment is needed to accomplish cremation Release Instructions: I hereby specifically authorize the release the cremated remains to: ________________________________________________________________ __________________________ Name of authorized individual Phone Number ________________________________________________________________ __________________________ Name of authorized individual Phone Number PRIORITY CREMATION (may incur additional charge): Cremated remains needed by or within (circle) l2Hrs /24 Hrs (Date/Time): The undersigned hereby agrees to hold harmless and indemnify A Bay Area Crematory Inc., its officers and employees from any and all liability, costs, expenses, or claims resulting from this ●Casket or alternative container that the deceased will be cremated in (type/description)●Urn(s) that cremated remains are to be placed in by crematory (quantity and description)● SPECIAL INSTRUCTIONS:The undersigned hereby agrees to hold harmless and indemnify A Bay Area Crematory Inc., its officers and employees from any and all liability, costs, expenses, or claims resulting from this authorization. Number of authorizing signatures required _____ Executed at this day of Year 2018 x Print Name Relationship Address Phone Print Name Relationship Address Phone if additional signatures are required copy this page and attach to packet
Death Certificate Order Page
Death Certificates: Death Certificates will be ordered on the next business day after the cremation permit has been issued. Death Certificates may be acquired two different ways:
Listed below is the current cost of each certified death certificate based upon the county where the death occurred:
I authorize aDirectCremation.com to obtain the death certificates of the above Decedent and send them via USPS to the below address.
If you marked YES on the line above, please state the number of death certificates you want us to order:
Leave this empty:
Signed by Daniel Reitz Signed On: February 19, 2018
If you have questions about the contents of this document, you can email the document owner.
Document Name: Online Version
Agree & Sign