Horswell, Bessie Scorse Whispering Maples Memorial Gardens Inc.
PO Box 186 Ellenburg Depot. New York 12935
AUTHORITY TO CREMATE
(This Authority signed by the proper relative or legal custodian of deceased, together with
Burial Permit, must be filed at th,: office of Whispering Maples Memorial Gardens Inc., before
cremation mey take place.)
I hereby request and authorize Whispering Maples Memorial Gardens Inc. to cremate the
remains of: /
(NAME) (SEX)
(ST EET-CITY-STATE-ZIP CODE)
who died on or about the day of 19
I represent that, to the best of my knowledge, the deceased has no pacemaker in his or
her body.
DISPOSITION OF CREMATED REMAINS
I hereby direct Whispering Maples Memorial Gardens Inc. to pulverize the Cremains, if
necessary, and to dispose of the remains as follows:
Mail to: izS
(F ER L DIRECTOR OR FAMILY)
LLAZ� / ti _1?�
(STREET-CITY-STA E-ZIP CODE)
Other Arrangements•
(PLEASE SPECIFY)
I certify that I have full power to give the above Authority to Cremate and to direct the
the above Disposition; and I agree to protect, defend and save harmless Whispering Maples Mem—
orial Gardens Inc. and the Funeral Director from any and all claims and demands for liabilities,
losses and/or damages which may be made against them, or either of them, by reason of, or
connected with, any action taken by them under the above Authority to Cremate and/or Dis—
position granted and directed by me, whether such claims or demands are or are not groundless,
false,-or fraud nt. ✓��
ITNESS NAT RE OF RELATIVE OR LEG REP.
FUNERAL 1 R RELAT ON TO D, EASED R AUTHORITY TO SIGN
Al �/ �y
ADDRES6 ADDRESS
ImporIx
tant: The The Funeral Director should make adequate inquiries of the deceased's medical
doctor and relatives and any hospital involved to assure that deceased has no pacemaker im—
planted in his or her body. If any pacemaker was implanted, it must be removed before the body
is delivered for cremation.