Vital Statistics Form

Release Form
NAME OF DECEASED:
DATE OF BIRTH:
MM slash DD slash YYYY
AGE:
LOCATION OF DECEASED
Please put full address of location below.
ADDRESS OF LOCATION DECEASED:
Street Address Address Line 2 City State ZIP Code
I undersigned hereby authorizes the release of the above named decedent to
CREMATION SOCIETY OF AMERICA to care and prepare for disposition. I hereby
represent that I am the nearest degree of relationship to the deceased.
Signed
Legally Authorized Next of Kin
Relationship to Deceased
Witness Signature:
Print Name
CREMATION SOCIETY OF AMERICA

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