phone: 920.468.4111 or toll-free: 800.750.4222

Authority to Cremate and Order for Disposition

I (We), the undersigned (the "Authorized Agent(s)"), hereby request and authorize Proko Wall Funeral Home & Crematory, Inc. (hereinafter referred to as the "Funeral Home") 1630 E. Mason Street Green Bay, WI 54302 - (920) 468-4111 to take possession of and make arrangements for the cremation of and the final disposition of the Decedent named below (the "Decedent") in accordance with and subject to the provisions set forth in this document, at Proko Wall Funeral Home & Crematory, Inc. (hereinafter referred to as the "Crematory") in accordance with and subject to its rules and regulations, and any applicable state or local laws or regulations.

  
     
  
     

Mechanical, radioactive devices or implants in the Decedent may create a hazardous condition when placed in a cremation chamber. All pacemakers and radioactive implants must be removed prior to delivery of the Decedent to the crematory.

  
     

We have arranged for the Funeral Home to remove or arrange for the removal of these devices and to properly dispose of them prior to cremation. I understand that if the Funeral Home has not been notified about such devices or implants, and not instructed to remove them, that I/we are responsible for any damages caused to the crematory or crematory personnel by such devices or implants.

Cremation will take place after all of the following conditions have been met.

  • Any scheduled ceremonies or viewing have been completed.
  • Civil and medical authorities have issued all required permits.
  • All necessary authorizations have been obtained, and no objections have been raised. (Wisconsin only).
  • 48 hours have transpired since the death occurred.

The Crematory, or authorized agents, is authorized to perform the cremation upon receipt of the human remains, at its discretion, and according to its own time schedule, as work permits, without obtaining any further authorization or instructions. All cremations are performed individully. The Crematory will only place the human remains of one individual in the cremation chamber at a time.

THE CREMATION PROCESS

Cremation is the technical process, using heat and flame, that reduces human remains to bone fragments. The reduction takes place through heat and evaporation. Cremation shall include the processing, and may include the pulverization, of the bone fragments. Please refer to the detailed description of the cremation process of this form, which are incorporated herein by this reference.

CASKET/CONTAINERS

The Crematory requires that an acceptable container be used for the cremation. Please refer to the requirements set out on this authorization.

URNS/TEMPORARY CONTAINERS

After the cremated remains have been processed, they will be placed in the designated urn or container. The Crematory will make a reasonable effort to put all of the cremated remains in the urn or container, with the exception of dust or other residue that may remain on the processing equipment. If the urn or container is not sufficient in size to hold the cremated remains, any excess will be returned in a temporary container or handled as provided below.

DECLARATION OF INTENT FOR THE DISPOSITION OF CREMATED REMAINS

I (We) authorize the Crematory to return the cremated remains of the Decedent to the possession and custody of the Funeral Home. I (We) understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the Decedent are returned to the possession and custody of the Funeral Home. I (We) hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the Decedent as stated below.

I understand that in the event the cremated remains have not been permanently interred or picked up by me or my designated representative within 120 days from the date of cremation, the Funeral Home is authorized to lawfully dispose of unclaimed cremated remains pursuant to Wisconsin law. I understand that disposal may include the commingling of the cremated remains with other cremated remains and that thereafter the remains of the Decedent shall not be recoverable

Engrave exactly as follows:

In the event all cremated remains do not fit in the receptacle I have chosen, I direct the Funeral Home, or its duly authorized agents to:
  
  
  

I HEREBY DIRECT AND AUTHORIZE THE RELEASE/DELIVERY OR SHIPMENT OF SAID CREMATED REMAINS (INITIAL ONE)

Deliver said cremated remains to:

For the purpose of:

Place in storage to be claimed within 120 days. If unclaimed within 120 days, I understand that the cremated remains will be disposed of pursuant to Wisconsin Law and the urn, or cremains container will be disposed of without further notice or authorization.

I appoint the Funeral Home as my agent to make shipment of said remains via the U.S. Postage Mail (certified, return receipt), or scheduled air shipment (PROPER CONTAINER OR URN REQUIRED BY COMPANY). I am aware that the Funeral Home’s services have been fully completed when the cremated remains leave the Funeral Home and that the Funeral Home is only acting as my agent for my accommodation only in carrying out these instructions. I understand that the Funeral Home assumes no responsibility to the Post Office, common carrier or agent.

Deliver to:

Cemetery for the purpose of interment/entombment (I understand there is a separate charge for this service at the cemetery):

  • Placement of cremated remains in niche;
  • Placement of cremated remains in cremorial;
  • Interment of cremated remains in ground cremation space.

Other:

I/We hereby certify that the Decedent left the following surviving heirs at law:

  
     
  
     
  
     
  
     
  
Names & Relationship

If the legal next of kin or if all persons of the same degree of kinship are not signing below, a written explanation must be completed by the person(s) signing below as Authorizing Agent.
Separate authorization(s), if necessary, shall be attached to and considered part of this form.

DISCLOSURES, WARRANTIES AND PERMISSIONS (INITIAL EACH)

,

I/We certify that the deceased person named above has not given other specific directions concerning the disposal of his/her remains.

,

I/We the undersigned, hereby certify that I am the closest living next of kin of the Decedent and that I am related to the Decedent as his/her

or that I otherwise serve (served) in capacity of

to the Decedent, that I have charge of the remains of the Decedent and as such possess full legal authority and power, according to the laws of Wisconsin to execute this authorization form and to arrange for the cremation and disposition of the cremated remains of the Decedent. In addition, I am aware of no objection to this cremation by any spouse, child, parent or sibling specified.

,

I/We have been offered the opportunity to personally identify the remains and assume full responsibility for the identify. I give permission for the Funeral Home to photograph the Deceased prior to cremation for identification purposes and give permission for the Funeral Home to maintain that photograph in their files.

,

I/We give my express permission for the following:

  • The incidental or inadvertent commingling of the cremated remains.
  • The processing of the remains and resulting incidental commingling of the cremated remains.
  • The disposal by the Crematory of metal or other nonhuman material recovered to which may be affixed bone particles or other human residue.

,

I/We understand that if I wish to remove and/or retain any item from the remains, I must do so directly or by authorized agent prior to the cremation process.

INDEMNITY

I/We declare under penalty of perjury that the foregoing certifications, representations and statements are true and correct, and that this statement is being made to induce the above named Funeral Home and Crematory to cremate (or cause to be cremated) the remains of the Decedent named above. I agree to hold harmless, indemnify and defend the above named Funeral Home and Crematory as well as their representatives, directors, officers, agents, employees and shareholders, from and against all claims, liabilities or damages whatsoever (including reasonable attorney’s fees) which may result from this authorization and order including the failure to properly identify the remains, failure to take possession of or make proper arrangements for the final disposition of the cremated remains, the processing of remains, shipping of remains, any explodable or harmful impact, infectious diseases, other persons claiming rights to control disposition of the remains, or any other cause. No warranties, expressed or implied, are made and damages shall be limited to the amount of the cremation fee paid.

SIGNATURE OF AUTHORIZING AGENT(S) THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL. READ THIS ENTIRE DOCUMENT CAREFULLY BEFORE SIGNING.

By executing this cremation authorization form, as Authorizing Agent(s), the undersigned warrants that all representations and statements contained on this document are true and correct, that these statements were made to induce the above named Funeral Home and Crematory to cremate the human remains of the Decedent, and that the undersigned have read and understand the provisions contained on the front and the back of this document.

Executed at , this , day of 20


Email address will only be used to send a copy of this completed form.

Relationship to Decedent:
Phone No.
Address:

Email address will only be used to send a copy of this completed form.

Relationship to Decedent:
Phone No.
Address:

Email address will only be used to send a copy of this completed form.

Relationship to Decedent:
Phone No.
Address:

Email address will only be used to send a copy of this completed form.

(Signature of Funeral Director as Witness for Signature(s) of Authorizing Agent(s))

ADDITIONAL TERMS AND CONDITIONS

THE CREMATION PROCESS

Cremation is performed to prepare the deceased for memorialization and it is carried out by placing the deceased in a casket or alternative container and then placing the casket or container into a cremation chamber, or retort, where they are subjected to intense heat and flame. During the cremation process, it may be necessary to open the cremation chamber and reposition the deceased in order to facilitate a complete and thorough cremation. Through the use of a suitable fuel, incineration of the container and its contents is accomplished by raising the temperature substantially (extreme temperature) and all substances are consumed or driven off, except bone fragments (calcium compounds) and metal (including dental gold and silver and other non-human materials) as the temperature is not sufficient to consume them.

Due to the nature of the cremation process, any personal possession or valuable materials such as dental gold and silver, or jewelry (as well as any body prostheses or dental bridgework) that are left with the Decedent and not removed from the casket or container prior to cremation may be destroyed and become non-recoverable, or if not destroyed, will be disposed of by the Crematory at its sole discretion. The Authorizing Agent understands that arrangements must be made with the Funeral Home to remove any such possessions or valuables prior to the time that the Decedent is transported to the Crematory.

Following a cooling period, the cremated remains, which will normally weigh several pounds in the case of an average-size adult, are then swept or raked from the cremation chamber. The Crematory makes a reasonable effort to remove all of the cremated remains from the cremation chamber, but it is impossible to remove all of them, as some dust and other residue from the process are always left behind. In addition, while every reasonable effort will be made to avoid commingling, inadvertent or incidental commingling of minute particles of cremated remains from the residue of previous cremations is a possibility, and the Authorizing Agent understands and accepts this fact.

After the cremated remains are removed from the cremation chamber, all non-combustible materials (insofar as possible), such as dental bridgework, and materials from the casket or container, such as hinges, latches, nails, etc., will be separated and removed from the human bone fragments by visible or magnetic selection and will be disposed of by the Crematory with similar materials from other cremations in a non-recoverable manner, so that only the human bone fragments will remain.

When the cremated remains are removed from the cremation chamber, the skeletal remains often contain recognizable bone fragments. Unless otherwise specified, after the bone fragments have been separated from the other material, they will then be mechanically processed (pulverized), which includes crushing or grinding and incidental commingling of the remains with the residue from the processing of previously cremated remains, into granulated particles of unidentifiable dimensions, virtually unrecognizable as human remains, prior to placement into the designated container.

CASKET/CONTAINERS

All caskets and alternative container must meet the following standards:

  • Be composed of materials suitable for cremation;
  • Be able to be closed to provide a complete covering for the human remains;
  • Be sufficient for handling with ease;
  • Be resistant to leakage or spillage;
  • Be able to provide protection for the health and safety of crematory personnel.

The Crematory is authorized to inspect the casket or alternative container, including opening it if necessary. In the event there is leakage or damage, the Crematory may contact the Authorizing Agent (Funeral Home) directly for instructions. The Crematory reserves the right to open the casket or alternative container to verify the identity of the deceased.

Many caskets that are comprised of combustible materials also contain some exterior parts, e.g., decorative handles or rails, that are not combustible and that may cause damage to the cremation equipment. The Crematory, at its sole discretion, reserves the right to remove these non-combustible materials prior to cremation and to discard them with similar materials from other cremations and other refuse in a nonrecoverable manner.

URNS/TEMPROARY CONTAINERS

In the event the urn or other container selected is insufficient to accommodate all of the cremated remains, the excess will be placed in a separate receptacle or disposed of as provided on the front of this form. The separate receptacle will be kept with the primary receptacle and handled according to the disposition instructions on this form. Unless a suitable urn is provided for the cremated remains, the Crematory will place the cremated remains in a container furnished by the Crematory which is not designed for shipment.

This submitted form will be sent to any email address(es) entered in the form.