Authorization to Release
Authorization to Release Pursuant to your rules and regulations, I authorize the release of the Remains of:
(First)
(Middle)
(Last)
to Argos Funeral Services for final disposition. I am the legal next of kin for the above decedent, and declare by my signature below that I have full right to authorize this release. I agree to hold harmless all parties involved to affecting this release, including Argos Funeral Services, its agents, employees, and representatives of any and all liability.
Place of Removal Name Street Address City Phone
Type Apt/Suite Zip
State Ext
Fax
Person with right to control disposition Name Street Address City Phone
Relationship Apt/Suite Zip
State E-mail
Yes
Does anyone hold a health care directive or power of attorney for health care for the decedent?
✔
No
Personal Belongings
Does the Decedent has a Pacemaker or implanted Battery Operated Device?
✔
Yes
No
CHARGES: I understand that I am to pay Argos Funeral Services all current charges incurred by performing this removal in full prior to completion of services. SIGNATURE
Date
Print Name
Relationship
(First)
(Middle)
(Last)
to Argos Funeral Services for final disposition. I am the legal next of kin for the above decedent, and declare by my signature below that I have full right to authorize this release. I agree to hold harmless all parties involved to affecting this release, including Argos Funeral Services, its agents, employees, and representatives of any and all liability.
Place of Removal Name Street Address City Phone
Type Apt/Suite Zip
State Ext
Fax
Person with right to control disposition Name Street Address City Phone
Relationship Apt/Suite Zip
State E-mail
Yes
Does anyone hold a health care directive or power of attorney for health care for the decedent?
✔
No
Personal Belongings
Does the Decedent has a Pacemaker or implanted Battery Operated Device?
✔
Yes
No
CHARGES: I understand that I am to pay Argos Funeral Services all current charges incurred by performing this removal in full prior to completion of services. SIGNATURE
Date
Print Name
Relationship
