Pet Release / Authorization Form 1 Pet Info / Owner Info2 Pet Release / Authorization for Final Disposition3 Terms and Conditions for Cremation Authorization Form Name of Pet*Date* Date Format: MM slash DD slash YYYY ID#Type of Pet*DogCatAge*BreedWeight (lbs)*Male / Female*MaleFemaleDate of Death* Date Format: MM slash DD slash YYYY Date of Birth Date Format: MM slash DD slash YYYY Owner Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Cell (optional)Email* This Authorization Form is required to be completed and signed prior to the final disposition of your pet. CREMATION IS AN IRREVERSIBLE AND FINAL PROCESS. It is important that you understand the cremation process and different options available prior to signing it. We want you to fully understand the information provided in this Authorization Form, so we will be pleased to answer any questions you may have. I/We represent that I/We have the right to authorize the cremation of the Pet's remains and warrant that I/We are the Owner or an Agent of the Owner ("Authorizing Agent"). I/We have read and checked all required Pet Disclosures as listed on the reverse side. I/We have read and understand the description of the different available cremation processes described on the reverse side including the final disposition/return of cremated remains; by checking the button below, I/We authorize the following:Select one of the following:*Private Cremation - Ashes Scattered* Private Cremation; I/We shall receive my pet's cremated remains.* Communal Cremation; the Crematory shall scatter all cremated remains and I/We will not receive any cremated remains.Memorial ItemsI/We have been informed of memorial items and choose the following Items Selected BelowNO Memorial ItemsThe following Urn(s) to hold the cremated remains:I'm interested in other memorialization items:JewelryMemorial ServicePayment (to be filled out by employee) Cremation Price: Urn: Memorials/Keepsakes: Other: Tax: Total: RELEASE AND CERTIFICATION I/We agree to release and indemnify the Veterinarian, the Funeral Home, the Crematory, their officers, directors, agents and employees, from any claim, liability, cost or expense resulting from their reliance on or performance consistent with the directions, declarations, representations, authorizations and agreements herein. I/We agree that the Veterinarian, Funeral Home's and Crematory's liability for negligent acts (of itself or its agents or employees) is limited to a refund of the cremation fees paid by me/us. I/We warrant that all representations and statements contained in this form are true and correct. I/We have read and understood all pages of this document. The authorization for cremation and disposition was executed on this day:* Date Format: MM slash DD slash YYYY Today's Date and Current Time.This authorization for cremation and disposition was executed this time:* : Hour Minute AM PM Authorizing Agent Name (Owner’s Name)*Cremains Received By*I warrant the truthfulness of the information provided in this application.Electronic Signature*I understand checkbox* I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance. CREMATION OPTIONS Cremation is performed to prepare the remains of the pet for final disposition. It is carried out by placing the pet’s remains into a cremation chamber or retort where they are subjected to intense heat and flame. The cremation can be done in one of two ways, including Private and Communal. A PRIVATE or INDIVIDUAL CREMATION is a cremation procedure during which only one animal’s body is present in the cremation chamber during the cremation process. A COMMUNAL CREMATION is a cremation procedure where multiple pets are cremated together without any form of separation. These commingled cremated remains are not returned to owners. CREMATION PROCESS During the cremation process, it may be necessary to open the cremation chamber and reposition the remains of the animal in order to facilitate a complete and thorough cremation. Through the use of suitable fuel, the incineration of the container and its contents is accomplished and all substances are consumed or driven off, except bone fragments (calcium compounds) and metal other non-combustible materials, as the temperature is not sufficient to consume them. Due to the nature of the cremation process, any possessions or materials, such as collars or tags that are left with the animal and not removed prior to cremation may be destroyed or if not destroyed, will be disposed of by the Crematory. The Authorizing Agent understands that arrangements must be made to remove any such personal possessions or materials prior to the time that the animal is transported to the Crematory. Following a cooling period, the cremated remains shall be recovered by manual means, such as brushing, and industry-specific mechanical means, such as vacuuming, in order to retrieve the cremated remains from the cremation chamber. Although the Crematory will take reasonable efforts to remove all of the cremated remains from the cremation chamber, some dust and other residue from the process will be left behind. Depending on the cremation option, there may or may not be more commingling, or mixing, of cremated remains. Active commingling occurs between animals during the cremation and/or retrieval process when multiple animals are cremated together in the same chamber. This type of commingling can be minimized with effective portioning but it is impossible to assert that it can be eliminated entirely. Active commingling cannot, by definition, occur with a private cremation. However, while every effort will be made to avoid commingling, inadvertent and incidental commingling of minute particles of cremated remains from the residues of previous cremations is possible. The Authorizing Agent understands and accepts that some incidental comingling is possible under any cremation option. After the cremated remains are removed from the cremation chamber, all non-combustible material (insofar as possible) will be separated and removed from the animal bone fragments by visible or magnetic selection. Other non-bone fragment foreign material recovered with the cremated remains shall be removed prior to processing so that only animal bone fragments will remain. Non-bone fragment and foreign material may be commingled with other like material and shall be disposed of in a dignified manner, and in accordance with all applicable laws. The Authorizing Agent understands and authorizes Crematory to dispose of these materials with similar materials from other cremations in a non-recoverable manner, including recycling. When the cremated remains are removed from the cremation chamber, the skeletal remains often will contain recognizable bone fragments. Unless otherwise specified, after the bone fragments have been separated from the other material, they will be mechanically processed, pulverized. The process of crushing or grinding may cause incidental commingling of the remains with the residue from the processing of previously cremated remains. These granulated particles of unidentifiable dimensions, which are virtually unrecognizable as animal remains, will then be placed into a designated container based on the type of cremation identified above (Private or Communal). WITNESSING Witnessing a cremation can be an emotional experience. Witnesses are assuming the risks involved and fully release the Funeral Home and Crematory from any liability. To the extent permitted by the Crematory, the persons identified on a Cremation Witness Acknowledgment Form are authorized to be present prior to and during the cremation of the animal’s remains and during the removal of the cremated remains from the cremation chamber. Witnessing of any aspect of the cremation and processing procedure shall be in compliance with all applicable law and any safety regulations. If you desire witnesses, you must list the witness names, and all witnesses must sign an additional Cremation Witness Acknowledgment Form. FINAL DISPOSITION OF CREMATED REMAINS Following the cremation, the Authorizing Agent directs the Crematory and/or Funeral Home to undertake the actions set forth on the reverse side to arrange the final disposition of the cremated remains. Cremated remains shall only be released, delivered, mailed or disposed of by the Cemetery or Funeral Home in a dignified manner, in accordance with the law, and with expressed written consent of the Authorizing Agent. If the cremated remains are shipped at any time, the Authorizing Agent directs that the Crematory or Funeral Home utilize registered U.S. mail with a return receipt or a shipping service that uses an internal system for tracing the location of the cremated remains during shipment and requires a signed receipt of the person taking delivery of the cremated remains. The Authorizing Agent understands that if no arrangements for the final disposition of the cremated remains have been made within sixty (60) days after the cremation or if the Authorizing Agent has not taken delivery of or caused the delivery of the cremated remains, or in the event the arrangements of the final disposition have not been carried out within the sixty (60) day period because of the inaction of a party other than the Crematory, Funeral Home, or Veterinarian, then the Crematory, Funeral Home or Veterinarian may dispose of the cremated remains in any dignified manner, including scattering. PET DISCLOSURES* I/We further represent and warrant that the animal has not bitten any person or other animal during the past ten (10) days, is not suffering from Rabies, and has not been exposed to other animals suffering from Rabies. ValidationLeave field unchanged. For validation purposes. ----- FOR OFFICE USE ----- Vet Clinic: Pick up of Deceased Pet: Referral Source Billing • Clinic • Family Pre-Plan Other services for family: Grief Support: Grief Info: Pet Loss Support Group: Pick Up Details: Arrangement Details: Visitations: Payment Information CC Check or Cash CC Information MC VISA Discover Amex Expiration Date, Security Code, Number NameThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
