Name Ofdeliverypersonandlicense#/Registration#(Printfullname-Last,First,Ml):______

ReceiptofHumanRemainsatCrematory

PleasereviewandprovidetherequiredInformationbelow:(PrintLegiblyorType)

DecedentInformation / FullName(Last,First,MiddleName)
DOB: / DOD: / Time of Death: / Gender (M/F):
DOB:DOD:ITimeofDeathIGender(MIF)
ReceiptofHuman
Remains
(ProvideRequested
Information) / DateandTimeofReceiptofHumanRemains:Date:Time:
From:(CircleOne)FuneralEstablishmentIPersonwithRighttoFinalDispositionOther
(Only provide information that applies to the circled item above)
NameofEstablishment/IndividualorPersons:
StreetAddress:
City:ICounty:IState:IZip:
PhoneNumber(s):
Verifications / JewelryRemoved:(CircleOne) YES I NOIfYes: AttachAuthorization
•IfNo,needauthorizationtocremate allremainingjewelry-
WandingPerformed:(CircleOne) YES I NO ForeignObjectsInbody: DonotAccept
Remains
RadiologicalImplants:(CircleOne) YES I NODateAllowedtoCremate:------
-IfYes,(atleast5daysfromplacementofimplantor5daysfromreceiptofhumanremains
ForeignObjectswithbody notsafetobecremated:(CircleOne) YES I NO
IfYes, returntopersondeliveringHumanRemains:ListItems:(Itemsnotsafeforcremation)
-(Print):
DateTimeRefrigerated

Name ofDeliveryPersonandLicense#/Registration#(PrintFullName-Last,First,Ml):______

Signature: .Date: .Permit/License #: ______

Name ofCrematoryOperatorand License#/Registration#)(PrintFullName-Last,First,Ml):

Signature: Date: Permit #: ______

ReleaseofCrematedHumanRemainsfromCrematory

PleasereviewandprovidetherequiredInformationbelow:(PrintLegiblyorType)

CremationDate __-__-____ / CremationDisc#:CrematedBy:
Release.ofCrematedHuman
Remains
(SelectOneandanswerallquestions) / ReleaseDateandTimeofCrematedRemains:
DATE(XXIXXIXXXX):TIME(XX:XXAM/PM):
PersonAcceptingCrematedHumanRemains: PrintFullName(Last,First.Ml):
FROM:(CircleOne)FuneralEstablishmentITransporterIPersonActingasFuneralDirector
NameofFuneralEstablishmentIPerson:
StreetAddress:
City:ICounty:IState:IZip:

NameofthePersonAcceptingtheCrematedHumanRemains: _

Signature: Date: License/Permit #:

NameofCertifiedCrematoryOperatorReleasingCrematedHuman

Remalns:Signature:Date:Permit #:______

FinalVerificationofHumanRemainsToBeCremated

(ImmediatelyBeforePlacementinCremator)

Pleasereviewandprovidethe requiredinformationbelow:(PrintLegiblyorType)

Date:______Decedent(PrintFull Name-Last,First,Middle):______

DateofDeath(Month/Date/Year):______

Crematedwithin48HoursofReceipt:(Yesor No):______

Timeof Death: ______

IfNoExplainWhy:______

CertifiedCrematoryOperatorCompletingForm(PrintFullName-Last,First,Ml):______

Permit#:

CheckList / FinalVerification
Completed(Yes/No) / IfNo,"STOP"Take
FollowingAction
CopyofCompletedDeathCertificate
AllItemsAppear ConsistentwithCopyof DeathCertificate
•Gender
•Race
•Age
VerifyNamewithNameonDeathCertificate
BurialTransit Permit
CremationIDForm
CremationAuthorizationForm

SignatureofCertifiedCrematory OperatorDate