Authorization to Accept or Decline Embalming

*TO
Funeral Establishment Name

Re: (Decedent)

Embalming is the addition to, or the replacement of, body fluids by chemical preservatives or the application of chemical preservatives for the temporary preservation of the body.

I understand that embalming is not required by law.

*I, (your name)

DO request embalming.

DO NOT request embalming.

I understand that for storage or embalming purposes the decedent may be transported to the following location:

*Location / Name / Address

The undersigned hereby represents that he/she has the legal right to control disposition of the remains of the decedent.

Signature

Relationship to Decedent

Executed

Date

Time

City / State

The above statement regarding embalming and storage was read and/or provided to

*Their Name

Relationship to Decedent

Who DID authorize embalming at the above named funeral establishment.

Who DID NOT authorize embalming at the above named funeral establishment.

*Funeral Home Phone

Date Authorization Granted

Time Authorization Granted

Funeral Establishment Office Only

This section is to be completed by the funeral establishment representative who is executing this authorization to accept or decline embalming. I declare under penalty of perjury that the foregoing is true and correct.

Executed

Date

Time

City / State

*Funeral Establishment Rep (Print Name)

Signature