RELATIONSHIP OF REPRESENTATIVE: The REPRESENTATIVE warrants and represents to the FUNERAL HOME that the relationship between the REPRESENTATIVE and the DECEDENT is as indicated.

AUTHORITY OF REPRESENTATIVE: The REPRESENTATIVE warrants and
represents to FUNERAL HOME that the REPRESENTATIVE is the person or the appointed agent of the person who by law has the paramount right to arrange and direct the disposition of the remains of the DECEDENT and that no other person(s) has a superior right over the right of the REPRESENTATIVE. EMBALMING AUTHORIZATION: The REPRESENTATIVE authorizes and directs the FUNERAL HOME, its employees, independent contractors, and agents (including
apprentices and/or mortuary students under the direct supervision of a licensed embalmer), to care for, embalm and prepare the body of the DECEDENT.

 

The REPRESENTATIVE acknowledges that this authorization encompasses permission to embalm (if authorized) at the FUNERAL
HOME facility or at another facility equipped for embalming. In providing this authorization.
 

REPRESENTATIVE acknowledges that embalming is not an exact science and that results are dependent upon a number of factors, including, but not limited to the conditions under which. the
death occurred, time lapse between death and the onset of the embalming procedure, physical condition at the time of death, medications, life-saving procedures, cause of death, storage
procedures of the releasing institution, natural elements, tissue/organ. donations, and post-mortem (autopsy) examinations.
 

INDEMNIFICATION: The REPRESENTATIVE agrees to indemnify and holdharmless the FUNERAL HOME from any claims or causes of action arising or related in any respect to this authorization for embalming or the FUNERAL HOME's reliance thereon.

I, the REPRESENTATIVE authorize FUNERAL HOME and
it's agents to remove the decedent and to transfer to FUNERAL HOME facilities and to embalm if authorized herein.