Resident Address: Town Where Death Occurred: Date of Death: Signature of Custodian Date Signed: Resident Address of Custodian: Entombment SpecifY Location: Name of Custodian of Body Please Print/Date Signed: Custodian's Tel: # (Including Area Code:

Relationship to Decedent: Signature Funeral Director Date Signed Funeral Home Name: Funeral Home Name: Time of Death: Sex: DOB: Signature: Date Signed: Name of Witness #1: Address of Witness #1: Signature of Witness #1: Name of Witness #2: Address of Witness #2: Signature of Witness #2: Resident Address of designated custodian: Name of designated custodian #1: Relationship to person self-authorizing cremation: Resident Address of designated custodian #1: Resident Address of designated custodian #2: Custodian #1 Telephone No: Custodian #2 Telephone No: Tel #: Burial Specify Location: Return to Person responsible for accepting cremated remains: Name: PM: OffAM: OffOther Person Notified: Date Signed 3: Date Signed2: Date Signed3: Address of Witness: Relationship to custodian 1: CH Designated: OffCH Unable: OffBurial Location: OffBurial Person: OffBurial Other: OffCheck Entomb: OffAddress Responsible: Other disposition: Registrar Sign: Date of Cremation: Time of Cremation: Cremation AM: OffPM Cremation: OffCrematory Name: Person In Charge Sig: Crematory Date Signed: