CREMATION AUTHORIZATION

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CREMATION AUTHORIZATION

The undersigned authorizes Good Shepherd, in accordance with and subject to Federal, State, and Good Shepherd rules and regulations, to cremate the remains of:

(Animal First Name)

(Family Last Name)

Dog Cat Other who died on _____ / _____ / _____.

I am related to the deceased animal as: owner, DVM, Other ____________.

I have the right to authorize this cremation and the disposition of the cremated remains. I understand that due to the nature of the cremation process any valuable material will either be destroyed or not recoverable. Any personal possessions accordingly have been either removed or may be destroyed. I further agree that I will indemnify and hold harmless Good Shepherd, their officers, and employees from any liability, cost, expenses or claims resulting from this authorization and subsequent disposition.

Signature of Relative or Legal Representative:

_____________________________

DATE:____ / _____ / _____

Witness:

_____________________________

DATE:____ / _____ / _____

ATTENDING D.V.M. (please print): _________________________________________

URN SELECTED: _______________________

PICK –UP

Date:

By:

Cremains Returned

YES

WEIGHT

________ lbs.

Hospital or Clinic Stamp:

Ship To: (if different from Hospital or Clinic)