AUTHORITY TO CREMATE

The undersigned hereby requests and authorizes GARDNER FUNERAL HOME/COLUMBIA HILLS MEMORIAL CHAPEL and COLUMBIA RIVER CREMATORY to cremate the body of:

Date of Birth:                                                  Date of Death:                                                              Pacemaker: Yes No


contained in (type of container):

The cremated remains are to be placed in (type of urn):

Supplied by____________________________________ Inurned/buried at___________________________________

OR shipped/released to___________________________ For disposition at___________________________________

Until disposition arrangements have been completed, the undersigned will be assessed a storage fee for cremated remains held in our receiving vault after 30 days. Please provide this information about the person responsible for final disposition:

Name__________________________________________ Telephone_ (__ )________________________________

Address

City________________________________ State_________________ ZipCode______________________________

Relationship to deceased___________________________________________________________________________

Other instructions or special handling requirements:_______________________________________________________

I have read the Disclosure Form on the reverse side of this form and understand the cremation process.

I hereby certify that I have the right to authorize this cremation and the disposition of the cremated body. I further agree that I will indemnify and hold harmless Gardner Funeral Home/CHMC and Columbia River Crematory from any claims to the contrary. (initials)______________

I understand that because of the nature of the cremation process, any valuable material remaining with the body may be consumed or not recoverable. Any personal possessions have been removed from the body or, if not, I order them destroyed before the cremation process. (initials)___

I hereby authorize Gardner Funeral Home/CHMC and Columbia River Crematory to dispose of/recycle any materials, prostheses, or other foreign elements separated from the cremated body. (initials)_____

Recoverable remains in excess of the capacity of the urn or temporary containers selected by me are to be placed in a separate container for disposition as directed by me. (initials)_____

I understand that surgically implanted devices such as pacemakers, which may or may not contain power sources, must be removed from the body prior to the cremation process because of the possibility of explosion. I, therefore, have instructed the funeral director to remove such devices prior to cremation. (initials)_________________________

I agree to be liable for any damage to the crematory or injury to personnel in the event of my failure to properly permit such removal. (initials)__________

I certify I have received the Cremation Disclosure Form, which is found on the reverse side of my copy of the Authority to Cremate.

Signed____________________________________ Date_______________________

Relationship to deceased or authority to sign__________________________________

Address______________________________ City/St/Zip_______________________

Witness______________________________________________________________

Cremated remains received by:_______________________ Relationship:__________

Date______________ Gardner Funeral Home/CHMC/Columbia River Crematory 1270 N. Main Ave.

White Salmon, WA 98672

CREMATION DISCLOSURE FORM

GARDNER FUNERAL HOME/CHMC / COLUMBIA RIVER CREMATORY

As required by Washington State Law, human remains must either be embalmed or refrigerated upon receipt by a funeral director or crematory. At Gardner Funeral Home/CHMC, there is a charge for either service on your “Statement of Goods and Services.” The appropriate charges will reflect the services you select. In general, if the cremation is delayed beyond two days for reasons not directly under the control of Gardner Funeral Home/CHMC you may be charged additional refrigeration charges.

Cremation is a process through which human remains are reduced to elemental bone fragments approximately 7 pounds) through a process of subjecting the body to intense heat and flame at a temperature in excess of 1600 degrees Fahrenheit.

Any casket or cremation container in which the human body is encased is consumed in the cremation process.

Certain portions of the casket may not be combustible, such as handles, hinges, latches, nails or screws. These materials are removed from the cremation chamber or the cremated body by visual selection, magnetic selection or a combination of both. Certain types of caskets are not combustible such as fiberglass or metal caskets. The body will be transferred to an alternative container and cremated, and the casket will be destroyed. It is the responsibility of the funeral director to notify you if these circumstances pertain to the cremation you are authorizing.

Upon completion of the cremation process, all recoverable cremated remains will be vacuumed or swept from the cremation chamber, together with any non-combustible materials which accompanied the body. Remains thus recovered will be cleaned of foreign materials such as casket parts, prostheses and similar materials. Prostheses and other foreign elements recovered from cremated remains will be disposed of or recycled in accordance with state law, unless otherwise directed.

Unless otherwise requested, the cremated remains will then be processed to fragments of less than five (5) millimeters in diameter (Washington Administrative code 98-40-060 and Revised Code of Washington 68.04.110). Processing is accomplished by a mechanical grinding and crushing procedure.

Following processing, all recoverable cremated body fragments will then be placed in a temporary container or in the urn ordered by you. Should the volume of cremated remains be such as to exceed the capacity of the container to be used, the additional cremated remains will be placed in a separate container. Gardner Funeral Home/CHMC assumes no responsibility for the temporary or permanent disposition or storage of cremated remains unless specifically authorized and ordered by a separate contract. Cremated remains for which no disposition instructions have been made nor financial arrangements completed are subject to the provisions of Washington Administrative Code 98-40-080, which authorizes the disposition of unclaimed cremated bodies in any manner it may be suitable.

FOR YOUR INFORMATION

Cremation is NOT the final disposition, nor is the placing the cremated remains in storage at a funeral home final disposition. The cremation process simply reduces the decedent’s body to cremated remains. These cremated remains usually weigh several pounds and are usually in excess of 150 cubic inches. Some provision must be made for the final disposition of these cremated remains. There are several options available to you. Cremated remains may be buried, placed in a columbarium or niche wall, retained or scattered. If the option selected for final disposition includes scattering, then the cremated remains will not be recoverable. Furthermore, if scattering is performed in a common area, then the cremated remains may be commingled with parties of other cremated remains that have been previously scattered. Sometimes, people scatter because it was the decedent’s request. However, then the loved ones are left with no permanent and/or tangible place to go to “be with” the decedent. Cremated remains can be, and often are, divided among family members and friends and then those individuals may decide what they would like to do with their portion of the cremated remains. Some people place the remains in a keepsake urn and keep it close. Some people scatter. Some people bury the cremated remains beside a favorite spot where they can remember the decedent. These options should be explored before a final decision is made.

Vital Information for Death Certificate


Name

First:                                      Middle:                                      Last:                                        Suffix:

Date of Death (MM/DD/YYYY):

County of Death:

Gender:

Age:

Social Security Number:

Was Decedent ever in U.S. Armed Forces?:   yes/no/unknown

Birthdate (MM/DD/YYYY):

Birthplace (city/town/county, state/foreign country):

Decedent's Education:

8th grade or less                                             9th - 12th grade; no diploma                            High school graduate or GED completed

Some college credit, but no degree               Associate degree (e.g., AA, AS)                       Bachelor's degree (e.g., BA, AB, BS)

Master's degree (e.g., MA, MS, MEng, MEd, MSW, MBA)                   Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD)

Was Decedent of Hispanic Origin?

No, not Spanish/Hispanic/Latino                       Yes, Mexican, Mexican American, Chicano

Yes, Puerto Rican                                               Yes, Cuban

Yes, other Spanish/Hispanic/Latino (specify)

Decedent's Race (check one of more races to indicate what the decedent considered himself/herself to be)

White                         Black or African American                               American Indian or Alaska Native (name of enrolled or principal tribe)

Asian Indian                 Chinese                                                              Filipino

Japanese                      Korean                                                              Vietnamese

Other Asian (specify)       Native Hawaiian                                               Guamanian or Chamorro

Samoan                       Other Pacific Islander (specify)                 Other (specify)

Decedent's Residence (number, street, apt. number, city/town, county, state/foreign country, zip code):

Was Decedents Residence inside City Limits?  yes/no/unknown 

Approximately how long had the decedent lived at that residence?

Marital Status at time of Death:

Married                                   Married, but separated                         Widowed

Divorced                                 Never Married                                      Unknown

Spouse's Name (first, middle, last name before first marriage):

Decedent's Usual Occupation (type of work done for most of working life--do not use retired):

Kind of Business/Industry (do not use company name):

Decedent's Father's Name (first, middle, last, suffix):

Decedent's Mother's Name (first, middle, last name before first marriage):

Informant's Name (person supplying this information):

Informant's Mailing Address:

Informant's Relationship to Decedent: