Authorization for Cremation

Kiser Undertakings dba Lone Star Cremation

1804 Owen Ct. Suite 112 Mansfield TX 76063 | (817) 546-0108

THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING!

Cremation and disposition of the remains of (DECEASED NAME) (hereinafter referred to as the deceased.)

Date of Death: (Completed by Lone Star) _______________________

Time of Death: (Completed by Lone Star) _______________________

I (NAME OF PERSON AUTHORIZING CREMATION) Confirm and declare that I possess the complete legal authority to authorize the cremation of the above-named deceased and that I am not aware of any person with a superior or equal priority right.

OR Confirm there are other person(s) that have an equal priority right to authorize the cremation and all reasonable efforts to contact that person(s) have failed. Furthermore, I believe that said person(s) would not object to the cremation and agree to indemnify and hold harmless the funeral establishment and the crematory establishment for any liability arising from performing the cremation without the person’s authorization.

VIEWING OF THE DECEASED PRIOR TO CREMATION (Select One): No Viewing / Yes, I want to view (Additional charges will apply and the Date and Time will be determined)

List any items of value delivered to the crematory with the deceased and their disposition:

I hereby request and authorize KISER UNDERTAKINGS L.L.C dba LONE STAR CREMATION to take possession of and plan for the cremation of the human remains of the deceased and receive the cremated remains from the crematory. The authorizing agent assumes responsibility for the disposition of the cremated remains. We will release the cremated remains to the authorizing agent or his designated agent or ship the cremated remains to the authorizing agent or dispose of the cremated remains not earlier than the 121st day following the date of cremation if the cremated remains have not been claimed by the authorizing agent.

The cremation processing and disposition of the remains of the deceased authorized herein shall be performed in accordance with all governing laws, the rules, regulations, and policies of the crematory and funeral home, and the following terms and conditions. It is the policy of the crematory to require that the remains of the deceased be placed in some type of minimum container. If the deceased is not in a container when it reaches the crematory, then the minimum container will be furnished and charged to the funeral home. When a casket is used, the crematory is authorized to remove and dispose of handles, ornaments, and any other non-combustible 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 container made of non-combustible material, I authorize the remains of the deceased to be removed prior to cremation and placed in a combustible container. We further authorize the crematory to dispose of any non-combustible casket in any lawful manner it deems appropriate.

To my knowledge, the deceased remains do or do not contain a pacemaker or other electronic medical implant. Such implant(s) could result in damage to the crematory, its workers, and equipment, and I authorize the removal of said devices prior to cremation. The cremation container containing 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 authorize the crematory to open the cremation chamber during the cremation process and reposition the remains of the deceased to facilitate a complete and thorough cremation.

Certain items including but not limited to body prosthesis, dentures, dental bridgework, dental fillings, jewelry, and any other personal articles accompanying the remains of the deceased may be destroyed during the cremation process. I 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. I 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 metal and to dispose of such materials.

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. Unless an urn or container suitable for shipment is provided, the crematory will place the cremated remains of the deceased in a container made of plastic and covered with cardboard which is destructible and will not be held liable for any damages that might occur during shipment. In the event the container or provided urn is insufficient to accommodate all 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 container or urn.

I understand and acknowledge that even with the exercise of reasonable care and 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 remaining in the cremation chamber and/or devices utilized to process the cremated remains. I hereby authorize the crematory to dispose of any such residual particles in any lawful manner it deems appropriate.

I agree to indemnify, release, and hold the crematory, funeral home, their affiliates, agents, employees, and assigns harmless from any and all loss, damages, liability, or causes of action (including attorney’s fees and expenses of litigation) in connection with the cremation and disposition of the cremated remains of the deceased as authorized herein, or my 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.

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

DISCLOSURE / DISCLAIMER FORM

(The Federal Trade Commission requires certain disclosures and prohibits misrepresentations in the making of funeral arrangements. This DISCLOSURE / DISCLAIMER FORM is a check list that those we serve are asked to read and sign.)

I/We made the arrangements for the funeral and final disposition of the remains of the person to be cremated do hereby attest to the following:

• I/We was given/shown/viewed pricing online or a General Price List in person.
• I/We were not told that embalming is required by law and were told that the law does not require embalming except in certain special cases. If embalming was provided, this was done with my/our express permission.
• I/We were not told that any law requires embalming for direct cremations, immediate burial, a funeral using a sealed casket, or if refrigeration is available and the funeral is without viewing or visitation and with a closed casket.
• I/We were not told that any law requires a casket for direct cremation or that a casket other than an unfinished wood box is required for direct cremation or for direct disposition.
• I/We were told that state law does not require the purchase of an outer burial container or any of the funeral goods or services I/We selected except as set forth on the "Statement of Funeral Goods and Services Selected."
• No claims were made to me/us as to the merchandise or other offerings of this funeral firm (embalming, casket, outer burial container) that embalming or the use of any merchandise available from this funeral firm would delay the decomposition of the remains for a long-term or indefinite time or would protect the body from graveside substances when such was not the case.
• No representations or warranties were made to me/us about the protective features of caskets or outer burial containers other than those made by the manufacturer.
• The only warranties expressed or implied granted in connection with goods sold with the funeral service I/we arranged were the expressed written warranties, if any, extended by the manufacturers thereof. No other warranties of merchandising fitness for a particular purpose were extended to us.
• I/We were not told that the amount of each of the cash advance items was the cost to the funeral firm. We were told the cost might be different based on volume or cash discounts or other professional/trade customs.
• I/We give permission to KISER UNDERTAKINGS to give out death certificates or information on the deceased or us at our request to any insurance companies or government agencies that request said death certificates.

STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED

KISER UNDERTAKINGS 1804 Owen Ct. Ste. 112, Mansfield TX 76063 | (817) 546-0108 TX License #4372

Charges are only for those items selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain the reasons in writing below. If you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve if you selected arrangements such as a direct cremation or immediate burial. If we charged for embalming, we would explain why below.

In the event you wish to question any aspect of our service, you may contact our office. If you have any complaint which cannot be resolved, you may direct such complaint to the Texas Funeral Service Commission, 1801 Congress Avenue, Suite 11.800, Austin, TX 78701. (512) 936-2474.

DECEASED NAME: _______________________ DATE: _______________________ CREMATION PACKAGE: _______________________

Additional Services: (May Add… Please refer to your itemized order.)

MERCHANDISE:

• Cardboard Cremation Container: Included
• Hard Plastic Temporary Urn: Included
• Additional Merchandise: (May Add… Please refer to your itemized order.)

CASH ADVANCES: Incurred by our funeral home(s) on buyer(s) behalf. Certain items may have to be estimated and will be so noted.) We charge you for our services in obtaining permits and death certificates.

• Death Certificates: $21 (Additional copies may have been added. Please refer to your itemized order.)
• Permits: $35
• Crematory Fee: Included

If any legal cemetery or crematory requirement has required the purchase of any of the items listed above, we will explain the requirement below:

Crematory Requires Cremation Container (Included in Package)

* Please Note: This contract for goods and services only represents the base charge for the package you selected and the known cash advances. Any additional merchandise or professional fees will/were approved by you and are represented on the invoice/order that you placed.