I hereby request, authorize, and direct Tri City Diversified Services, LLC (hereinafter “Crematory”) to cremate in accordance with the subject
to its rules and regulations the remains of
The cremation will occur within 10-14 days of the date of
, unless the Just4cremation.com
(hereinafter cremation specialist) whom I have engaged (and whose name is listed above), and by whom Crematory was engaged as a
subcontractor to perform the cremation, having made good faith efforts in that period to obtain the following required authorization, is unable
by the end of that time to obtain same; (1) medical examiner approval for the cremation; or (2) signature of a physician on the death certificate
as to cause of death. If the cremation is delayed due to the delay in receiving the above-identified required authorizations, the cremation will
occur within 48 hours after the receipt of the aforesaid required authorizations.
Terms and conditions of the performance of cremation:
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I understand and agree that the remains must be stored before cremation, and then cremated in a leak-resistant, rigid, combustible
cremation container. Following cremation, the cremated remains, consisting primarily of bone fragments, will be processed, and
mechanically pulverized to an unidentifiable consistency. I acknowledge that some particles of the cremated remains may inadvertently
become commingled with particles of other cremated remains during the cremation process or pulverization process.
If the urn or container is insufficient to accommodate all of the cremated remains, any excess cremated remains will be placed in a
secondary container and returned to me, or disposed of in any lawful manner at the discretion of Just4cremation.com or Crematory.
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Section 497.607(2) Florida Statutes, provides that if, after a period of 120 days from the date of cremation the cremated remains have not been claimed, Just4cremation.com or Crematory may dispose of the cremated remains by scattering them at sea, placing them in a licensed cemetery scattering garden or pond, placing them in a church columbarium or otherwise as provided by administrative rule.
I hereby indemnify, release and hold harmless Just4cremation and Crematory, their agents, employees, representatives, and assigns from
any and all loss, damage, liability, costs, expenses, or claims resulting from the Authorization, including attorney’s fees and costs of litigation
in connection with the cremation and disposition, including shipping, of the cremated remains.
I am a legally authorized person as defined by 497.005(39) Florida Statutes (set forth below). I authorize the cremation of the remains
identified herein. I attest that I am not aware of any person in my priority class or higher who objects to this authorization. I acknowledge
that no person may make a claim objecting to the cremation of the remains identified herein against Just4cremation.com or Crematory,
when my Funeral Home and Crematory, act upon the authorization of the legally authorized person executing this authorization.
*Legally authorized person’ means, in the priority listed; (a)The decedent, when written inter-vivos authorizations and directions are
provided by the decedent; (b)The person designated by the decedent as authorized to direct disposition pursuant to Pub.L. No. 109-163,s
564, as listed on the decedent’s United States Department of Defense Record of Emergency Data, DO Form 93, or its successor form if the
decedent died while serving military service as described in 10 U.S.C.s. 1481 (a) (1).(8)in any branch of the United States Armed Forces,
United States Reserve Forces, or National Guard; (c) The surviving spouse, unless the spouse has been arrested for committing against the
deceased an act of domestic violence as defined ins. 741.28 that resulted in or contributed to the death of the deceased; (d) A son or
daughter who is 18 years of age or older, € A parent; (f) A brother or sister who is 18 years of age or older, (g) A grandchild who is 18 years of
age or older, (h) A grandparent, or (i) Any person in the next degree of kinship. In addition, the term may include, if no family member exists
or is available, the guardian of the dead person at the time of death; the personal representative of the deceased; the attorney in fact of the
dead person at the time of death; the health surrogate of the dead person at the time of death; a public health officer, the medical examiner,
county commission, or administrator acting under part II of chapter 406 or other public administrators; a representative of a nursing home
or other health care institution in charge of final disposition; or a friend or other person not listed in this subsection who is willing to assume
the responsibility as the legally authorized person. Where there is a person in any priority class listed in this subsection, the funeral
establishment shall rely upon the authorization of anyone legally authorized person of that class if that person represents that she or he is
not aware of any objection to the cremation of the deceased’s human remains by others in the same class of the person making the
representation or of any person in a higher priority class.
By signing below, I agree that the above information is true and correct. Any errors may lead to additional costs in correcting state documents.
Thank you for filling out the Authorization for Cremation & Disposition Form.
