CREMATION AUTHORIZATION

I/We hereby authorize the William F. Conroy Funeral Home, Inc. to cremate:

Full Name of Deceased:

Age:

Who died at (am / pm)

on (date of death):

My relationship to the deceased:

Instructions for the disposition of cremated remains:

I hereby certify that I/we have the right to make this authorization. I agree to indemnify and hold harmless the Funeral Home and the crematory from any liability, claims or expenses as a result of this authorization. I further certify that the remains contain no pacemaker or other implants that could be explosive and I agree to liable for any damage or injury due to the failure to instruct the removal of these items. I further understand that due to the nature of the cremation process, any materials, such as dental gold, will be destroyed and non recoverable. In addition, I understand that any personal effects, if not removed, will be destroyed and may be disposed of by the crematory.

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Address:

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Address:

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Address:

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Address:

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Address:

Witness:

Funeral Home: 2944 Chartiers Ave. Pittsburgh PA 15204

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