Springer and Son Funeral Home and Crematory
4150 SW 185th  P.O Box 5308 Aloha, Oregon 97006-5308 Ph 503.356.1000 Fax 503.356.1013

AUTHORIZATION FOR CREMATION AND DISPOSITION

Notice:  This is a legal document.  It contains important provisions concerning cremation.  Cremation is an irreversible and final process.
Read this entire document carefully before signing.
I/We hereby authorize and direct Springer and Son Funeral Home  , “FUNERAL HOME”
hereafter, and Springer & Son Aloha Crematory, ‘CREMATORY” hereafter, subject to its terms and conditions (see below), to cremate the remains of: (name of Deceased) 
Sex Age Years (State ID Disk Number)
My relationship to the above named Deceased is that of   (relationship to Deceased of person giving such authorization)            If other please specify relationship 

Upon my oath, and under penalty of perjury, I hereby swear and affirm that there is no other person having a prior right to give this authorization per Oregon Revised Statutes 97.130 (see below), and to control the remains of the above named Deceased except (Name and relationship of other person)   who have given me written or telegraphic instructions to sign this authorization on their behalf.  Said instructions are herewith filed with the CREMATORY.  By signing this authorization I further agree to release and hold the FUNERAL HOME and CREMATORY or contracted crematory, its affiliates and their agents, employees and assigns, harmless from any and all loss, damages, liability or causes of action (including attorneys fees and expenses of litigation) in connection with the cremation authorization and disposition of the ashes as authorized herein or the failure to identify properly the remains of the Deceased or take possession of or make permanent arrangements for the disposition of such ashes of the Deceased.

OREGON REVISED STATUTE 97.130 Right to control disposition of remains; delegation.
       (1) Any individual of sound mind who is 18 years of age or older, by completion of a written signed instrument or by preparing or prearranging with any funeral service practitioner licensed under ORS chapter 692 shall not be subject to cancellation or substantial revision.

       (2) A person within the first applicable listed class among the following listed classes that is available at the time of death or, in the absence of actual notice of the contrary direction by the decedent as described under subsection (1) of the section or actual notice of opposition by completion of a written instrument by a member of the same class or member of a prior class, may direct any lawful matter of disposition of a decedent’s remains by completion of a written instrument

a)    Spouse of the Decedent           

b)       A son or daughter of the Decedent 18 years of age or older

c)      Either parent of the Decedent

d)      A brother or sister of the Decedent 80 years of age or older

e)      A guardian of the Decedent at the time of death

a)      A person in the next degree of kindred of the Decedent

g)      The personal representative of the estate of the Decedent

h)      The person nominated as the personal representative of the Decedent in the decedent’s last will

i)        A public health officer

3)      The decedent or any person authorized subsection (2) of this section to direct the manner of disposition of the Decedent’s remains, may delegate such authority to any person 18 years of age or older, such delegation shall be made by completion of the written instrument described in subsection (7) of this section.  The person to whom the authority is delegated shall have the same authority under number (2) of this section as the person delegating the authority.

DISPOSITION OF THE ASHES
Urn Selection:
  Authorized agents/designee will pick up: Deliver to:  *Ship certified mail to:
Name of person/place or cemetery  
Telephone Number 
Street address  
City    State    Zip Code 

 *in the event of shipment by the U.S. Postal Service or other designated common carrier, I release the FUNERAL HOME and CREMATORY or its agents from any and all responsibility for any loss by such carrier.

DISCLOSURES, TERMS AND CONDITIONS

  1.   Yes  No  Does the Deceased have a heart pacemaker or any other type of implanted mechanical or radioactive devices?  Such devices may create a hazard when cremated.  The CREMATORY will not cremate any Deceased, with contains any type of devices.  In the event the deceased contains such devices, I/We hereby authorized the FUNERAL HOME  and/or CREMATORY to remove any such devices from the Deceased prior to cremation, and dispose of such devices at its discretion.

  2. For sanitation purposes, it is the policy of  CREMATORY, that the Deceased be placed in a rigid container. (A cardboard alternative container will meet this requirement).

  3. Personal items on the Deceased that are to be returned to the family prior to cremation:All items including, but not limited to, body prosthesis (hip joints, surgical pins, etc.) bridgework, dentures, gold inlays and fillings and jewelry or similar items, cremated with the deceased will lose their identity.  Any such items remaining with the ashes will be separated from the ashes and disposed of by the CREMATORY.

  4. If the ashes are left in the possession of the FUNERAL HOME or CREMATORY and not picked up within 180 days after the date of cremation, the FUNERAL HOME or  CREMATORY will make a reasonable effort to notify the family or authorized agent personally or by certified mail.  The notice will state that the ashes will be disposed of within 30 days of the date of the notice.  If there is no response from the family or authorized agent, the FUNERAL HOME or CREMATORY may dispose of the ashes as is legally practical.

  5. In the event the urn or container is insufficient to accommodate all of the ashes of the Deceased, any excess ashes will be placed in a secondary container and returned together with primary urn or container.

  6. The obligation of the FUNERAL HOME and CREMATORY is limited to the cremation of the Deceased and the disposition of the ashes as directed herein.  No warranties, expressed or implied are made and any damage shall be limited to a refund of the fee paid hereunder.

 By executing this form, the undersigned warrant(s) that all representations and statements contained in this form are true and correct, that these statements are being relied on my the FUNERAL HOME and CREMATORY and the undersigned has/have read and understood the provisions of this form.

Name and Relationship   ______________________________________ Date ___________

Name and Relationship   ______________________________________ Date ___________


THIS DOCUMENT MUST HAVE A SIGNATURE TO BE EXECUTABLE.

COMPLETION INSTRUCTIONS
After you have completed this form,
1) print it on paper
2) Sign it
3) Fax it to 503.356.1013

 This Facility Is Licensed By The Oregon State Mortuary & Cemetery Board