Castle Hill Funeral Home- Cremation Authorization
Castle Hill Funeral Home- Cremation Authorization 1219 Sheffield Ave Dyer, IN – 248 155th Place Calumet City, IL DECEASED NAME:___________________________________________________SEX:__________AGE:________ DATE OF BIRTH:__________________________DATE OF DEATH:________________________ CITY & STATE OF DEATH:_________________________________________________________ I hererby request and authorize CASTLE HILL FUNERAL HOME to take possession of and make arrangements for the cremation of the Deceased’s remains at Heights Crematory (230 E 11 th Street Chicago Heights, IL). To induce the funeral home and crematory to cremate, process and dispose of the Deceased’s remains. I, the undersigned, hereby certify, warrant, and represent and acknowledge ***INITIAL ITEMS 1-6*** 1. ___ ___ ___ I have the full legal right and authority to authorize the cremation, processing, and disposition of the Deceased’s remains. 2. ___ ___ ___I have read and understand the crematory/cremation requirements, procedures, and policies. 3. ___ ___ ___ I have not been denied the opportunity to personally identify the Deceased’s remains and assume full responsibility for the identification of the Deceased’s remains. 4. ___ ___ ___ I understand that if I wish to remove or retain an item from the Deceased’s remains, I must do so by authorizing agent prior to the cremation process. 5. ___ ___ ___ I give permission for Castle Hill Funeral Home or its duly authorized agent to remove and dispose of any pacemaker or other type of implanted mechanical or radioactive device. 6. ___ ___ ___ I understand that in the event the cremated remains have not been permanently picked up by me or my designated representative within 120 days of date of cremation, Castle Hill Funeral Home is authorized and directed to dispose of the unclaimed cremated remains in any lawful manner. DISCLOSURES 1.
Are there any special instructions? If yes, EXPLANATION:____________________________________________________________________________
2.
The deceased has the following implanted mechanical or radioactive devices and or prosthetic devices:___________________________________________
3.
At the time of the Deceased’s death did he/she have a disease that was infectious, communicable or dangerous to public health:_______________________
4.
Description of urn of additional container:___________________________________________________________________________________________
**In the event the urn or container is insufficient to accommodate all of the cremated remains, any excess cremated remains will be placed in a secondary container and will be returned together with the primary urn or container. ORDER FOR DISPOSITION I authorize Heights Crematory to cremate and process the Deceased’s remains and to return the cremated remains to Castle Hill Funeral Home. I understand that the services and obligations of the crematory shall be fulfilled when the cremated remains of the Deceased are returned to the possession and custody of Castle Hill Funeral Home. I hereby authorize the funeral home to arrange for disposition of the CREMATED REMAINS as follows: ***PLEASE CHOOSE AN OPTION _____ RELEASE TO - NAME AND ADDRESS_______________________________________________________________________________________________________________ _____DELIEVER TO CEMETERY_________________________________________________________________________________________________________________________ SHIP TO – NAME AND ADDRESS________________________________________________________________________________________________________________________
(If the legal next of kin is not signing below a written statement of explanation must be completed by the person signing below) ** I declare under penalty of perjury that the foregoing information is true and correct, and I make this statement to induce Castle Hill Funeral Home and Heights Crematory to cremate or cause to be cremated to remains of the Deceased. I agree to hold harmless, indemnify and defend Castle Hill Funeral Home and Heights Crematory against any claims, liabilities, damages, cost or expenses, including attorney fees, which may result from this authorization and order, including without limitation claims that arise from or relate to shipping, identity, kinship, explodable or harmful implant, infectious disease, or other person claiming right to control disposition of the Deceased’s remains. PRINTED NAME:_________________________________________________________________________________________RELATIONSHIP:________________________________________DATE:______________ ADDRESS:________________________________________________________________________________________________________SIGNATURE:____________________________________________________
PRINTED NAME:_________________________________________________________________________________________RELATIONSHIP:________________________________________DATE:______________ ADDRESS:________________________________________________________________________________________________________SIGNATURE:____________________________________________________
PRINTED NAME:_________________________________________________________________________________________RELATIONSHIP:________________________________________DATE:______________ ADDRESS:________________________________________________________________________________________________________SIGNATURE:____________________________________________________
FUNERAL DIRECTOR’S SIGNATURE
Notary of the Public: Sworn and Subscribed to me on this __________ day of _________, 20______ Notary:__________________________________________________My commission expires: 10/29/2021
______________________________________
*****Ceremonies and/or services that require the presence of the cremated remains MUST NOT BE scheduled prior to the cremation being complete; and/or authorization from the funeral home. The funeral home cannot guarantee the presence of the cremated remains for any service prior to authorization. INITIAL:_____ _____ _____
All cremations take place individually. All arrangements for identifying the deceased must be made known to the funeral home prior to cremation taking place. The cremation container containing the remains of the deceased will be placed in to the cremation chamber under extreme heat and will be totally and irreversibly destroyed. It is understood that even with exercise of reasonable care; it is not possible to recover all particles of the cremated remains of the deceased; and that some particles may inadvertently become comingled with particles of other cremated remains. The crematory is authorized to remove and dispose of any handles, ornaments, and any other noncombustible items attached to the cremation container prior to cremation. In the event of cremation of an infant or child, it is possible that NO cremated remains may be able to be recovered from the cremation chamber. INITIAL:_____ _____ _____ ILLINOIS DEATH – PRIOR TO CREMATION
1.
The funeral home will submit the death certificate electronically to the physician. The physician will complete the cause of death and electronically sign the death certificate. THIS PROCESS CAN TAKE SEVERAL DAYS. THE PHYSICIAN AND ONLY THE PHYSICIAN WILL DETERMINE HOW FAST THE DEATH CERTIFICATE GETS SIGNED.
2.
After the physician electronically signs the death certificate, the funeral home will apply for the county cremation permit through the Medical Examiner’s office. The cremation permit will be issued to the funeral home within 2 days of initial request.
3.
Once the funeral home has a completed death certificate from the physician and the county cremation permit has been issued; the funeral home will send the death certificate to the state of Illinois to become registered. The county will register the death certificate within 3 days.
4.
Finally, after the state of Illinois registers the death certificate, the funeral home can authorize cremation with the crematory.
5.
Cremation usually will take place 1-3 days after authorization. INITIAL:_____ _____ _____ INDIANA DEATH – PRIOR TO CREMATION 1.
Indiana law mandates a 48 hour holding period, prior to cremation taking place.
2.
The funeral home will submit the death certificate electronically to the physician. The physician will complete the cause of death and electronically sign the death certificate. THIS PROCESS CAN TAKE SEVERAL DAYS. THE PHYSICIAN AND ONLY THE PHYSICIAN WILL DETERMINE HOW FAST THE DEATH CERTIFICATE GETS SIGNED.
3.
After the physician completes the death certificate and the 48 hour holding period has expired; cremation will be authorized by the funeral home.
4.
Cremation usually takes place 1-3 days after authorization. INTIAL:_____ _____ _____
**********THE CREMATION PROCESS MAY TAKE SEVERAL WEEKS TO COMPLETE, THE FUNERAL HOME WILL PROMPTLY AUTHORIZE CREMATION AFTER ALL STATE REQUIREMENTS HAVE BEEN MET.**********
Are there any special instructions? If yes, EXPLANATION:____________________________________________________________________________
2.
The deceased has the following implanted mechanical or radioactive devices and or prosthetic devices:___________________________________________
3.
At the time of the Deceased’s death did he/she have a disease that was infectious, communicable or dangerous to public health:_______________________
4.
Description of urn of additional container:___________________________________________________________________________________________
**In the event the urn or container is insufficient to accommodate all of the cremated remains, any excess cremated remains will be placed in a secondary container and will be returned together with the primary urn or container. ORDER FOR DISPOSITION I authorize Heights Crematory to cremate and process the Deceased’s remains and to return the cremated remains to Castle Hill Funeral Home. I understand that the services and obligations of the crematory shall be fulfilled when the cremated remains of the Deceased are returned to the possession and custody of Castle Hill Funeral Home. I hereby authorize the funeral home to arrange for disposition of the CREMATED REMAINS as follows: ***PLEASE CHOOSE AN OPTION _____ RELEASE TO - NAME AND ADDRESS_______________________________________________________________________________________________________________ _____DELIEVER TO CEMETERY_________________________________________________________________________________________________________________________ SHIP TO – NAME AND ADDRESS________________________________________________________________________________________________________________________
(If the legal next of kin is not signing below a written statement of explanation must be completed by the person signing below) ** I declare under penalty of perjury that the foregoing information is true and correct, and I make this statement to induce Castle Hill Funeral Home and Heights Crematory to cremate or cause to be cremated to remains of the Deceased. I agree to hold harmless, indemnify and defend Castle Hill Funeral Home and Heights Crematory against any claims, liabilities, damages, cost or expenses, including attorney fees, which may result from this authorization and order, including without limitation claims that arise from or relate to shipping, identity, kinship, explodable or harmful implant, infectious disease, or other person claiming right to control disposition of the Deceased’s remains. PRINTED NAME:_________________________________________________________________________________________RELATIONSHIP:________________________________________DATE:______________ ADDRESS:________________________________________________________________________________________________________SIGNATURE:____________________________________________________
PRINTED NAME:_________________________________________________________________________________________RELATIONSHIP:________________________________________DATE:______________ ADDRESS:________________________________________________________________________________________________________SIGNATURE:____________________________________________________
PRINTED NAME:_________________________________________________________________________________________RELATIONSHIP:________________________________________DATE:______________ ADDRESS:________________________________________________________________________________________________________SIGNATURE:____________________________________________________
FUNERAL DIRECTOR’S SIGNATURE
Notary of the Public: Sworn and Subscribed to me on this __________ day of _________, 20______ Notary:__________________________________________________My commission expires: 10/29/2021
______________________________________
*****Ceremonies and/or services that require the presence of the cremated remains MUST NOT BE scheduled prior to the cremation being complete; and/or authorization from the funeral home. The funeral home cannot guarantee the presence of the cremated remains for any service prior to authorization. INITIAL:_____ _____ _____
All cremations take place individually. All arrangements for identifying the deceased must be made known to the funeral home prior to cremation taking place. The cremation container containing the remains of the deceased will be placed in to the cremation chamber under extreme heat and will be totally and irreversibly destroyed. It is understood that even with exercise of reasonable care; it is not possible to recover all particles of the cremated remains of the deceased; and that some particles may inadvertently become comingled with particles of other cremated remains. The crematory is authorized to remove and dispose of any handles, ornaments, and any other noncombustible items attached to the cremation container prior to cremation. In the event of cremation of an infant or child, it is possible that NO cremated remains may be able to be recovered from the cremation chamber. INITIAL:_____ _____ _____ ILLINOIS DEATH – PRIOR TO CREMATION
1.
The funeral home will submit the death certificate electronically to the physician. The physician will complete the cause of death and electronically sign the death certificate. THIS PROCESS CAN TAKE SEVERAL DAYS. THE PHYSICIAN AND ONLY THE PHYSICIAN WILL DETERMINE HOW FAST THE DEATH CERTIFICATE GETS SIGNED.
2.
After the physician electronically signs the death certificate, the funeral home will apply for the county cremation permit through the Medical Examiner’s office. The cremation permit will be issued to the funeral home within 2 days of initial request.
3.
Once the funeral home has a completed death certificate from the physician and the county cremation permit has been issued; the funeral home will send the death certificate to the state of Illinois to become registered. The county will register the death certificate within 3 days.
4.
Finally, after the state of Illinois registers the death certificate, the funeral home can authorize cremation with the crematory.
5.
Cremation usually will take place 1-3 days after authorization. INITIAL:_____ _____ _____ INDIANA DEATH – PRIOR TO CREMATION 1.
Indiana law mandates a 48 hour holding period, prior to cremation taking place.
2.
The funeral home will submit the death certificate electronically to the physician. The physician will complete the cause of death and electronically sign the death certificate. THIS PROCESS CAN TAKE SEVERAL DAYS. THE PHYSICIAN AND ONLY THE PHYSICIAN WILL DETERMINE HOW FAST THE DEATH CERTIFICATE GETS SIGNED.
3.
After the physician completes the death certificate and the 48 hour holding period has expired; cremation will be authorized by the funeral home.
4.
Cremation usually takes place 1-3 days after authorization. INTIAL:_____ _____ _____
**********THE CREMATION PROCESS MAY TAKE SEVERAL WEEKS TO COMPLETE, THE FUNERAL HOME WILL PROMPTLY AUTHORIZE CREMATION AFTER ALL STATE REQUIREMENTS HAVE BEEN MET.**********
