Reformatif Necessary and Print on Letterhead Stationary United States of America State

FORM A

To be NOTARIZED

REFORMATIF NECESSARY AND PRINT ON LETTERHEAD STATIONARY
UNITED STATES OF AMERICA
STATE OF
COUNTY OF

………………………………………………………………… (first and lastname), being duly sworn, deposes and says that he/she is a funeral director at ………………… (name of Funeral Home) duly licensed by the State of ……………………., and that he/she operates a funeral home at ………...…………….………………………………………………………………………………………………….(insert address) that he/she supervised the preparation of the last remains of ……………………………………………………….……………………………..(name and lastname of deceased) for shipment to Italy, and that he/she certifies and swears that the body has been enclosed in a wooden casket; that the casket has been soldered within a zinc liner and placed in a strong wooden or metal box; that the intersection of the different parts of the box are joined in dove-tail style, and the joint were first glued together and fastened with screws; that the box is bound with metal strips one (1) inch in width or more and eighteen (18) inches apart; that between the metal casket and the box is a filler of sawdust or wood shavings of a thickness of no less than 1’’ 3/4 inches; that in the chest and in the abdominal cavity of the body was injected at least one quart of a 3% solution of bichloride of mercury or a 5% solution of phenol, and the body was wrapped in a sheet saturated with a 3% solution of mercury bichloride.

The remains will be consigned to ………………………….(name of receiving Funeral Home in Italy)
And will be transported …………………………………………………………………………….(by air or sea)
Departing……………………………………. (city, state) at……………………..(time)
On or about ………………………………….(date)
Arriving………………………………………..(city, province in Italy) at……………………..(time)
On or about ………………………………….(date)
Entombment will be in ……………………………………….(name of Cemetery, city, province in Italy)

Deponent finally states that this shipment has no commercial value and to the best of his/her knowledge and belief meets the shipping requirements of transportation of remains to Italy.

Date,
Signed______
Subscribed to and sworn before me (signature of Notary Public)
This______
(Seal of notary public)