I/We, the undersigned (the Authorizing Agent), certify, warrant and represent that I/We have full legal right and authorityto authorize the cremation, processing and final disposition of the remains of

There are no other livingpersons who have a superior or equal right to act as the Authorizing Agent, or alternatively the following persons dohave a superior or equal right and I/we have made all reasonable efforts to contact them without success and have noreason to believe they would object to the cremation:

I/We hereby request and authorize F.B. PRATT & SON FUNERAL HOME, INC. (hereinafter referred to as the “Funeral Home”) to take possession of and make arrangement for the cremation of the remains of the Deceased at PRATT CREMATORIUM, (hereinafter referred to as the “Crematory”) and to proceed with the cremation upon receipt of the Deceased. The following items (valuables) need to return to the authorizing agent prior to cremation:

If yes,

The death occurred as a result of a disease declared by the Department of Health and/or Hospital to beinfectious, contagious, communicable, or otherwise dangerous to the public health? Yes No I/We authorize theCrematory to release the cremated remains of the Deceased to the possession and custody of the Funeral Home. I/Weunderstand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of thedeceased are returned to the possession and custody of the Funeral Home. I/We hereby authorize the Funeral Home toarrange for the disposition of the cremated remains of the Deceased as follows:

*Funeral Home and Crematory are not responsible for any loss or damage of cremated remains shipped via Registered Mail with U.S. Postal Service.

The cremation processing and disposition of the remains of the Deceased authorized herein shall be performed in accordance with all the governing laws, the rules, regulations and policies of the Crematory and Funeral Home, and the following terms and conditions:

1. The remains of the Deceased will not be accepted for cremation unless received by the Crematory in a combustible, leak resistant, rigid cremation container. The Crematory is authorized to remove and dispose of handles, ornament sand any other noncombustible items attached to the cremation container prior to cremation. In the event the remains of the Deceased are received by the Crematory in a casket or other container constructed of metal, fiberglass, or other noncombustible material I/We authorize the remains of the Deceased to be removed prior to cremation and placed in a combustible cremation container. I/We further authorize the Funeral Home or Crematory to make disposition of any such noncombustible casket in any lawful manner it deems appropriate.

2. Mechanical or radioactive devices implanted in the remains of the deceased (such as pacemakers, etc.) may create a hazard when placed in the cremation chamber. The Crematory will not cremate any human remains which contain any type of implanted mechanical or radioactive devices. In the event the remains of the Deceased contains such a device, I/We hereby authorize the Funeral Home, its agents and employees, to remove any such mechanical devices from the remains of the Deceased prior to cremation, and dispose of such items at its discretion.

contain any type of implanted mechanical orradioactive device. Listed below are all implanted mechanical and radioactive devices which the Funeral Home isauthorized to remove from the remains of the Deceased prior to cremation, and dispose of as indicated:

3. The cremation container containing the remains of the Deceased will be placed in the cremation chamber and will be totally and irreversibly destroyed by prolonged exposure to intense heat and direct flame. I/We authorize the Crematory to open the cremation chamber during the cremation process and reposition the remains of the Deceased in order tofacilitate a complete and thorough cremation.

4. Certain items including but not limited to body prostheses, dentures, dental bridgework, dental filings, jewelry, and other personal articles accompanying the remains of the Deceased, may be destroyed during the cremation process. I/We further authorize that if any items, other than the cremated remains of the deceased, are recovered from the cremation chamber, they may be separated from the cremated remains of the Deceased and disposed of by the Crematory.

5. I/We hereby authorize the Crematory to separate and remove from the cremation chamber all non combustible materials, including but not limited to hinges, latches, nails, jewelry and precious metals, and to dispose of such materials.

6. Following cremation, the cremated remains of the Deceased, consisting primarily of bone fragments, will be mechanically pulverized to an unidentifiable consistency prior to placement in an urn or other container.

7. Unless an urn or container suitable for shipment is purchased, the Crematory will place the cremated remains of the Deceased in a container that is not suitable for any type of shipment.

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

9. I/We understand and acknowledge, that even with the exercise of reasonable care the use of the Crematory’s best efforts, it is not possible to recover all particles of the cremated remains of the Deceased, and that some particles may inadvertently become commingled with particles of other cremated remains in the cremation chamber and/or other devices utilized to process cremated remains.

10. I/We hereby authorize the Crematory to dispose of any such residual particles in any lawful manner it deems appropriate. Unless I/We give specific written instructions in this Authorization, the cremation, processing & disposition of the remains of the Deceased will not be performed in accordance with any religious or ethnic customs.

11. In the event the cremated remains of the Deceased remain unclaimed for a period of 30 days, the Funeral Home shall give written notice to me/us by certified mail at the address(es) indicated below. I/We agree that in the event the cremated remains of the Deceased remains unclaimed, for a period of 120 days after the date such written notification is mailed, the Funeral Home is authorized and directed to dispose of the unclaimed cremated remains of the Deceased in any lawful manner it may deem appropriate.

12. I/We agree to indemnify, release and hold the crematory, Funeral Home, their affiliates, 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 and disposition of the cremated remains of the Deceased, as authorized herein, or my/our failure to correctly identify the remains of the deceased, disclose the presence of any implanted mechanical or radioactive devices, or take possession of, or make permanent arrangements for, the disposition of such remains.

13. Except as set forth in this Authorization, no warranties, expressed or implied, are made by the Funeral Home, Crematory or any of their respective affiliates, agents or employees.

14. I/We understand that this document does not contain a complete and detailed description of every aspect of the cremation process.

SIGNATURE OF PERSON(S) AUTHORIZING CREMATION AND DISPOSITION

I/We warrant that all representations and statements made herein are true and correct, and that I/We have read and understand the provisions contained in this document.