AUTHORIZATION FOR CREMATION & DISPOSITION

This is a legal document that contains important provisions concerning cremation. Please understand that cremation is irreversible, so please read this document very carefully before signing. I/We, the undersigned. certify, warrant and represent that I/We have the full legal right and authority, as a legally authorized person as defined in Florida Statutes 497.005(37), to authorize the cremation, processing and disposition for the remains of the late:

I/We hereby authorize Eric L. Wilson Funeral Service to take possession of and make arrangements for the cremation of the Decedent at EVERGLADES CREMATORIUM. Also, I/We give the Crematorium full authority to cremate the remains of the deceased, and hereby authorize the Crematorium to return the cremated remains to the funeral home herein identified or as indicated below. I/We understand that the services and obligation of EVERGLADES CREMATORIUM shall be fulfilled when the cremated remains are returned to the possession and custody of Eric L. Wilson Funeral Service. Please adhere to the following requests: Is special handling required? YES NO If yes, please describe:

No. of attendees Time Is a WITNESS CREMATION requested? YES NO If yes, Date The cremation, processing and disposition of the remains of the Decedent authorized herein shall be performed in accordance with all governing laws, rules, regulation and policies of EVERGLADES CREMATORIUM, and the following terms and conditions: 1. The remains must be placed in a combustible, leak resistant and rigid container in which to cremate. 2. Mechanical or radioactive devices implanted in the remains (such as Pacemaker) must be removed prior to cremation. Therefore, I/We authorize their removal prior to or after cremation and discarded according to laws and statutes. Please list items below: d) c) b) a) 3. Any cremation container wherein the remains are placed will be totally and irreversibly destroyed during cremation. I/We authorize the crematory to open the chamber during cremation in order to reposition the remains so as to facilitate a complete and thorough cremation. 4. Articles such as body prostheses, dentures, dental bridgework, jewelry, dental fillings, dental gold caps, any metal parts that remain of the cremation containers, or other personal articles accompanying the remains may be destroyed during cremation. I/We authorize the crematory to separate any fractions thereof and discard legally. 5. Following cremation, cremated remains consist primarily of bone and bone fragments, which are collected into a metal container and placed in a pulverizing machine before storing in a plastic bag and placed into a temporary cardboard cremation container. I/We authorize the crematory to pulverize all bone and bone fragments before placing in the temporary. I/We 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/our failure to correctly identify the remains of the Deceased, disclose the presence of any implanted mechanical or radioactive devises, or take possession of, or make permanent arrangements for, the disposition of such remains.

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