I hereby authorize Funeral At Sea to take possession of and make arrangements for the disposition of the cremated remains of:
| ______________________________ | ____________________ | |
| Name of Decedent | Number of Passengers | |
| _______________ | _______________ | |
| Date of Death | Date of Scattering |
In accordance with and subject to the terms and conditions set forth in this authorization; the Company's Rules and Regulations; and applicable federal, state, or local laws and regulations. I agree to pay a $200 nonrefundable deposit.I certify that I have the full legal right and authority to authorize the disposition of the cremated remains of the deceased.
I hereby authorize Funeral At Sea to make disposition of cremated remains of the deceased. I hereby direct Funeral At Sea to scatter said cremated remains at sea in accordance with State and Federal Law. I agree to pay funeralatsea.com a
Special Instructions
The obligation of Funeral At Sea shall be limited to the disposition of the cremated remains as directed herein. I agree to release and hold harmless Funeral At Sea, its affiliates and their agents, employees, successors and assigns from any and all loss, damage, liability or causes of action (including attorney's fee and expense of litigation) in connection with the disposition of the cremated remains of the deceased as authorized herein or respect to the identification of said cremated remains as being those of the deceased.
| ______________________________ | ___________________________ | |
| Name Printed | Street Address | |
| ______________________________ | ___________________________ | |
| Signature | City, State, Zip | |
| ______________________________ | ___________________________ | |
| Telephone | Relationship to Deceased | |
Mail checks payable to:
Funeral At Sea, P. O. Box 423, Oldsmar, FL 34677
Ph: 813-855-2093
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