Authorization Forms FETCH Data Source

Authorization Forms FETCH data source

Document list:

Authorization for release of remains
Transportation and shipment of human remains
Funeral Rule Disclosure2
Representation and indemnification regarding right of disposition
Authorization to release information to the media
Authorization to post obituary on funeral home website and other internet sites
Disclaimer of Agent Relationship
Disclaimer of warranties by purchaser of funeral merchandise
Embalming authorization
Authorization to conduct ID
Decline viewing of remains of the decedent
Cremation and disposition authorization2
Authorization to transfer possession of remains of the decedent
Directions to withhold embalming
Direction to arrange interment
Directions to mail cremated remains
Authorization for international shipment of remains
AZ Brochure
Authorization to Embalm – Texas
Cremation Authorization - Kentucky

Authorization for release of remains:

"FUNERAL HOME": FETCH funeral home name

"REPRESENTATIVE": FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

(Use Space Below for Additional Names)

"DECEDENT": FETCH name as it will appear (of decedent)

"INSTITUTION": FETCH current location facility name

ADDITIONAL REPRESENTATIVES

Name Relationship to Decedent

FETCH additional name & relationship if NO to closest living relative

Transportation and shipment of human remains:

"FUNERAL HOME": FETCH funeral home name

"REPRESENTATIVE": FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

"DECEDENT": FETCH name as it will appear (of decedent)

"DESTINATION": FETCH funeral home name

ADDITIONAL REPRESENTATIVES

Name Relationship to Decedent

FETCH additional name & relationship if NO to closest living relative

Funeral Rule Disclosure2:

"FUNERAL HOME": FETCH funeral home name

"REPRESENTATIVE": FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

"DECEDENT": FETCH name as it will appear (of decedent)

"DATE OF DEATH": FETCH date of death

The undersigned obtained a General Price List effective on: ___ FETCH effective date of GPL

The undersigned saw a Casket Price List effective on: ____ FETCH effective date of Casket Price List

Representation and indemnification regarding right of disposition:

FUNERAL HOME": FETCH funeral home name

"REPRESENTATIVE": FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

"DECEDENT": FETCH name as it will appear (of decedent)

Authorization to release information to the media:

FUNERAL HOME": FETCH funeral home name

"REPRESENTATIVE": FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

"DECEDENT": FETCH name as it will appear (of decedent)

ADDITIONAL REPRESENTATIVES

Name Relationship to Decedent

FETCH additional name & relationship if NO to closest living relative

Authorization to post obituary on funeral home website and other internet sites:

FUNERAL HOME": FETCH funeral home name

"REPRESENTATIVE": FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

"DECEDENT": FETCH name as it will appear (of decedent)

ADDITIONAL REPRESENTATIVES

Name Relationship to Decedent

FETCH additional name & relationship if NO to closest living relative

Disclaimer of Agent Relationship by Purchaser:

“AGENT": Insert “FuneralCompare, LLC and its website

“FUNERAL HOME": FETCH funeral home name

"PURCHASER": FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

ADDITIONAL REPRESENTATIVES

Name Relationship to Decedent

FETCH additional name & relationship if NO to closest living relative

Disclaimer of warranties by purchaser of funeral merchandise:

FUNERAL HOME": FETCH funeral home name

"PURCHASER": FETCH name of purchaser person

"MERCHANDISE": Customer write in field

ADDITIONAL REPRESENTATIVES

Name Relationship to Decedent

FETCH additional name & relationship if NO to closest living relative

Embalming authorization:

FUNERAL HOME": FETCH funeral home name

"REPRESENTATIVE": FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

"DECEDENT": FETCH name as it will appear (of decedent)

ADDITIONAL REPRESENTATIVES

Name Relationship to Decedent

FETCH additional name & relationship if NO to closest living relative

10.

Authorization to conduct ID:

FUNERAL HOME": FETCH funeral home name

"REPRESENTATIVE": FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

"DECEDENT": FETCH name as it will appear (of decedent)

ADDITIONAL REPRESENTATIVES

Name Relationship to Decedent

FETCH additional name & relationship if NO to closest living relative

11.

Decline viewing of remains of the decedent:

FUNERAL HOME": FETCH funeral home name

"REPRESENTATIVE": FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

"DECEDENT": FETCH name as it will appear (of decedent)

ADDITIONAL REPRESENTATIVES

Name Relationship to Decedent

FETCH additional name & relationship if NO to closest living relative

12.

Cremation and disposition authorization2:

Date FETCH date of completing this document

1. Name of Decedent: Date of Death: FETCH name as it will appear of decedent. FETCH date of death

Top of Form

Place of Death: Sex: M F Age: DOB: S.S.:

Bottom of Form

FETCH place of death. FETCH Gender; Male or Female. FETCH Age, calculated. FETCH date of birth. FETCH social security number of decedent

2. Name of Funeral Home: Address:

Crematory: Address:

FETCH funeral home name. FETCH funeral home address.

FETCH crematory name. FETCH crematory address.

3. Name of Authorizing Agent: Address:

Telephone No.: Relationship:

FETCH name of authorized representative=FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative. FETCH address of authorizing agent. FETCH phone number of authorizing agent. FETCH relationship of authorizing agent.

4. Name(s) of Other Persons:

FETCH names of other contact persons.

5. Description of Devices: CUSTOMER write in field

The Devices listed are to be removed and returned to the Authorizing Agent: CUSTOMER write in field

6. Casket or Alternative Container Selected: CUSTOMER write in field

7. Witnesses

CUSTOMER write in field
(Initials) (List of Witnesses)

10. Urn selected by Authorizing Agent. Description of urn: CUSTOMER write in field

12. Items to be delivered to Authorizing Agent: CUSTOMER write in field

15. Executed at ______, this ______day of ______, ______.

Authorizing Agent Name:______

Authorizing Agent Address:______

Signature of Authorizing Agent:______

Witness Name:______

Witness Address:______

Witness Telephone No.: ______Relationship:

FETCH current time, FETCH todays date

FETCH Authorizing Agent name

FETCH Authorizing Agent address

Signature of Authorizing Agent: E-SIGNATURE of authorizing agent

Witness name – CUSTOMER write in field

Witness address – CUSTOMER write in field

Witness telephone No – CUSTOMER write in field

Witness Relationship – CUSTOMER write in field

13.

Authorization to transfer possession of remains of the decedent:

"FUNERAL HOME": FETCH funeral home name

"REPRESENTATIVE": FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

(Use Space Below for Additional Names)

"RECIPIENT": INSERT the term “crematory” if Cremation was chosen. INSERT the term “Airline Air Cargo” if Transport Away was chosen. INSERT the term “cemetery” if Burial was chosen.

"DECEDENT": FETCH name as it will appear (of decedent)

ADDITIONAL REPRESENTATIVES

Name Relationship to Decedent

FETCH additional name & relationship if NO to closest living relative

14.

Directions to withhold embalming:

FUNERAL HOME": FETCH funeral home name

"REPRESENTATIVE": FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

"DECEDENT": FETCH name as it will appear (of decedent)

ADDITIONAL REPRESENTATIVES

Name Relationship to Decedent

FETCH additional name & relationship if NO to closest living relative

15.

Direction to arrange interment:

FUNERAL HOME": FETCH funeral home name

"REPRESENTATIVE": FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

"CEMETERY": CUSTOMER write in field

"DECEDENT": FETCH name as it will appear (of decedent)

ADDITIONAL REPRESENTATIVES

Name Relationship to Decedent

FETCH additional name & relationship if NO to closest living relative

16.

Directions to mail cremated remains:

FUNERAL HOME": FETCH funeral home name

"REPRESENTATIVE": FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

"DECEDENT": FETCH name as it will appear (of decedent)

"URN": FETCH name of urn from merchandise urn selection

Name: ______CUSTOMER write in field

Address: ______CUSTOMER write in field

17.

Authorization for international shipment of remains:

FUNERAL HOME": FETCH funeral home name

"REPRESENTATIVE": FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

"DECEDENT": FETCH name as it will appear (of decedent)

"INTERNATIONAL DESTINATION": CUSTOMER write in field

ADDITIONAL REPRESENTATIVES

Name Relationship to Decedent

FETCH additional name & relationship if NO to closest living relative

18.

AZ Brochure

NOTE: For all cases selecting an ARIZONA funeral home.

19.

Authorization to Embalm – Texas

NOTE: Only for EMBALMING cases selecting a TEXAS funeral home.

Name of Licensed Funeral Establishment ______FETCH funeral home name

Name of Deceased______FETCH name as it will appear (of decedent)

Date of Death______FETCH date of death

______Date Signed______

Signature of next-of-kin or Person Responsible for making arrangements for final disposition

INSERT electronic signature and date, IF giving Authorization to Embalm

The undersigned, who represents the deceased, hereby declares that having the legal authority to do so, refuses to give permission to embalm the above-named deceased individual. ______

Signature Date

INSERT electronic signature and date, IF Directions to withhold embalming

20.

Cremation Authorization – Kentucky

NOTE: Only for CREMATION cases selecting a KENTUCKY funeral home.

COMMONWEALTH OF KENTUCKY OFFICE OF THE ATTORNEY GENERAL CREMATION AUTHORIZATION FORM CR-1, #04-17

______(Crematory Name) FETCH name of crematory

______(Street Address) FETCH address of crematory

______(City, State, Zip Code) FETCH city, state, zip of crematory

______(Telephone Number) FETCH phone number of crematory

IDENTIFICATION OF DECLARANT OR DECEDENT (Please Print All Information On This Form)

Name: ______FETCH name as it will appear (of decedent)

Address:______FETCH address of deceased

City, State, Zip: ______FETCH city, state, zip of deceased

Age: ______Gender: ______Date of Birth: ______FETCH age, gender, DoB of deceased

Kentucky Law requires the individual’s remains to be identified before cremation can take place. The individual making the identification can be the authorizing agent(s), a family member, friend, coroner, or any other person, who has personal knowledge of the decedent or the ability to make positive identification and who accepts any liability arising from such identification.

Name of individual making identification: ______CUSTOMER write in field

Relationship: ______CUSTOMER write in field

Signature of individual making identification: ______CUSTOMER e-signature field

1. CREMATION AUTHORIZATION

The person legally entitled to order the cremation of a declarant or decedent is the authorizing agent(s). The right to control the disposition of the remains of a declarant or decedent devolves on the following in the order of authority of authorizing agent(s) listed below.

ORDER OF AUTHORITY OF AUTHORIZING AGENT(S): (check one that applies)
(1) ____ The individual executing a Funeral Planning Declaration, Form FPD-1 (attach original Funeral Planning Declaration).
(2) ____ The person named as the designee or alternate designee in a Funeral Planning Declaration, Form FPD- 1 (attach original Funeral Planning Declaration).
(3) ____ The person named in a U.S. Department of Defense form "Record of Emergency Data" (DD Form 93) or a successor form adopted by the United States Department of Defense, if the decedent died while serving in any branch of the United States Armed Forces (attach original form).
(4) ____ The decedent through a Preneed Cremation Authorization, Form CR-3 completed and executed before July 15, 2016 (attach original Form CR-3).
(5) ____ The surviving spouse of the declarant or decedent.
(6) ____ The surviving adult child of the declarant or decedent; OR a majority of the adult children if more than one (1) adult child is surviving; OR less than a majority of the surviving adult children by attesting in writing showing the reasonable efforts to notify the other adult surviving children of their intentions and that they are not aware of any opposition to the final disposition instructions by more than half of the surviving adult children. There are ____ surviving adult children.

CUSTOMER write in field

(7) ____ The surviving parent(s) of the declarant or decedent. If one (1) parent is absent, the parent who is present has the right to control the disposition by attesting in writing showing the reasonable efforts to notify the absent parent. Number of surviving parents _____. CUSTOMER write in field

(8) ____ The surviving adult grandchild of the declarant or decedent; OR a majority of the adult grandchildren if more than one (1) adult grandchild is surviving; OR less than a majority of the surviving adult grandchildren by attesting in writing showing the reasonable efforts to notify the other adult surviving grandchildren of their intentions and that they are not aware of any opposition to the final disposition instructions by more than half of the surviving adult grandchildren. There are ____ surviving adult grandchildren. CUSTOMER write in field

____ The surviving adult sibling of the declarant or decedent; OR a majority of the adult siblings if more than one (1) adult sibling is surviving; OR less than a majority of the surviving adult siblings by attesting in writing showing the reasonable efforts to notify the other adult surviving siblings of their intentions and that they are not aware of any opposition to the final disposition instructions by more than half of the surviving adult siblings. There are ____ surviving adult siblings.

CUSTOMER write in field

___ An individual in the next degree of kinship under KRS 391.010 to inherit the estate of the declarant or decedent or; OR a majority of those in the same degree of kinship if more than one (1) individual of the same degree is surviving; OR less than a majority of the individuals of the same degree of kinship by attesting in writing showing the reasonable efforts to notify the other individuals of the same degree of kinship of their intentions and that they are not aware of any opposition to the final disposition instructions by more than half of the individuals of the same degree of kinship. There are ____ surviving individuals of the following relationship ______.

CUSTOMER write in field CUSTOMER write in field

(11) ___ If none of the persons listed in sections (1) to (10) above are available, one of the following who attests in writing showing the good-faith effort made to contact any living individuals described in sections (1) to (10) above.
__ 1) A person willing to act and arrange for the final disposition of the decedent; or

__ 2) A funeral home that has a valid prepaid funeral plan that makes arrangements for the disposition of the decedent’s remains, if the funeral director makes the written attestation.

(12) ___ The District Court in the county of the decedent’s residence or the county in which the funeral home or the crematory is located.

2. The consumer is not required to purchase a casket for the purpose of cremation.
Type of casket or alternative container selected: ______

CUSTOMER write in field

3. FINAL DISPOSITION

Disposition of the cremated remains shall be by: (please mark and complete the chosen disposition)

1) Interment, at ______CUSTOMER write in field

Scattering in scattering area or garden, at ______CUSTOMER write in field
3) In any manner on private property with the permission of the owner, at ______CUSTOMER write in field
4) Delivery either in person or by a method that has an internal tracking system that provides a receipt signed by the person accepting delivery, to: ______

______CUSTOMER write in field

OTHER INFORMATION TO BE COMPLETED AT TIME OF INDIVIDUAL’S DEATH

Location where death occurred (city, county and state): ______FETCH place of death

Date of death: ______FETCH Date of Death

Did the declarant or decedent have any infectious or contagious disease? YES ____ NO ____
If yes, please explain: ______CUSTOMER write in field

Pacemakers, radioactive, silicon or other implants, mechanical devices or prosthesis may create a hazardous condition when placed in cremation chamber and subjected to heat. The following list describes all devices (including mechanical, prosthetic, implants or materials) which may have been implanted in or attached to the individual:

Description: ______CUSTOMER write in field

SIGNATURE OF THE DECLARANT OR AUTHORIZING AGENT(S)

If a written attestation is required, select and complete the attestation that applies:

 ___ For authorizing agent(s) listed in Order of Authority sections 6 (children), 8 (grandchildren), 9 (siblings), or 10 (next degree of kinship), the undersigned authorizing agent(s) attest that there are ____ in the authorizing class

CUSTOMER write in field

and ____ of us are authorizing the cremation

CUSTOMER write in field

of ______. FETCH Name as it appears of deceased

I or we have made reasonable efforts to notify the other _____ members of the authorizing class

CUSTOMER write in field

by (describe efforts): ______. CUSTOMER write in field

 ___ For an authorizing agent listed in Order of Authority section 7 (parent), the undersigned authorizing agent attests that I have made reasonable efforts to notify the other parent by (describe efforts): ______. CUSTOMER write in field

 ___ For authorizing agent(s) listed in Order of Authority section 11 (others), the undersigned authorizing agent(s) attest that a good-faith effort has been made to contact any living individual described in Order of Authority sections 1 through 10 by (describe effort): ______. CUSTOMER write in field

Executed at ______, CUSTOMER write in field

this ______day of ______, ______. FETCH current date.

Name: ______FETCH name of contact person, if YES closest living relative, if NO, FETCH name of closest living relative

Signature: ______CUSTOMER e-signature field

Address: ______FETCH address of contact person, if YES closest living relative, if NO, FETCH address of closest living relative

City, State, Zip Code: ______FETCH city, state, zip of contact person, if YES closest living relative, if NO, FETCH city, state, zip of closest living relative