Forms
NOVA Crematon Service # 1
435 N. Echo , FRESNO, CA 93701
(559) 266 - 9400
Information COVER LETTER
THIS INFORMATION contains several pages and forms that will be necessary should you elect to use
NOVA Cremation Service in Fresno. We provide services for the counties of FRESNO, MADERA, MERCED,
MARIPOSA, TULARE, and KINGS. As a Funeral Director, Funeral establishment, and embalming for all CALIFORNIA.
Never select a Funeral Director unless it’s to your advantage.
If you select to use these forms, Please use large block letters and numbers with BLACK ink only.
This information is NOT for return through your computer.
Your choice would be by regular post office or overnight express, or our fax. You must call before you are ready so we can turn on and monitor. Thank you.
ATTENTION: ____________________________________________________
TO: [ ] Telephone # [ ] e-mail___________________________
________________________________________________________________
PLEASE find the necessary application for:
o Person in charge of instructions.
o Statistical information for whom arrangements made for.
o Type of Services requested.
o Authorization to obtain custody of remains.
o AUTHORIZATION FOR CREMATION AND DISPOSITION.
o Price for Minimum Base rate and cost necessary.
o A promissory note and instructions for payment.
o Be sure to sign the “DECLARATION FOR DISPOSITION”
of cremated remains.
o Be sure to ‘X’ do_ DO NOT__ embalming, and signed, date {Exhibit 1}
o Instructions to FAX back information.
o Be sure to photo copy of your ID BACK TO ME.
THANK YOU DAVID Wm. LOPER, Director
Information RETURN FAX, PLEASE CALL (5 5 9) 2 6 6 - 9 4 4 0
Home Telephone, call prior calling. Scroll down for next page
NOVA Cremation Service FD1396, 435 N. Echo , FRESNO, CA 93701 (559) 266 - 9400 #2
A 1 PLEASE providing information about you, or the person in charge of arrangements.
DATE:______________YOUR TELEPHONE No: (_______ ) ___________________ FAX # If applicable
Person in charge of arrangements:_________________________ SPECIFY RELATIONSHIP
Your Address: ____________________________ []Spouse []Child []Parent []Next of KIN and/or Your City: _________________________ person legally entitled to Custody of remains and such decisions.
LIST:_________________________________.
Your County:___________________ State:_________________ Zip Code:_____________________
A 2 STATISTICAL INFORMATION FOR WHOM ARRANGEMENTS ARE MADE FOR.
FULL NAME: _____________________________________________________ AKA ________________
(FIRST) (MIDDLE) (LAST FAMILY NAME)
SEX: [] Male [] Female Military Service [] Yes [] NO [] Unknown
BIRTH DATE: __________/____________/____________ BIRTH State:___________________
SOCIAL SECURITY No._______-_______-______________ MARTIAL STATUS:[] Never married
[] Divorced [] Widowed [] Married
EDUCATION:0 ________0-11 [] 12nd [] HS Graduate [] Some College [] Associate
[] Bachelor’s [] Master’s [] Doctorate OR [] Professional
Spanish/Hispanic/Latino: [] YES____________ [] NO [] Yes, Mexican, Mexican American,or Chicano
[] Yes Central American Yes,South American Yes,Cuban Yes,Puerto Rican[] Yes,Spanish/Hispanic/Latino
RACE or Ethnicity (UP to three) [] White [] Black, African American, Negro [] Am. Indian / Alaska Native ( North, South, Central Am. Ind.) Specify Tribe_______ [] Native Hawaiian [] Guamanian ,Samoan
[] Other Pacific Islander________ [] Asian Indian [] Cambodian [] Chinese [] Filipino [] Hmong
[] Japanese [] Korean [] Laotian [] Vietnamese [] Other Asian Specify:____________________
[] Other Specify:_________________________________
Usual Occupation:_______________________[DO NOT use‘RETIRED)
Kind of business:_________________________________ Years in: ______
Usual Residence_______________________________________________City________________________
County: _____________Zip code:_______ Years in County________or SINCE _ _ _ _ State:_____
Name of Surviving SPOUSE: _____________________________________________________________________________________
FIRST MIDDLE LAST ( IF wife, use maiden name)
Name of FATHER:______________________________________________________________________________
FIRST MIDDLE LAST BIRTH STATE
Name of MOTHER:_____________________________________________________________________________
FIRST MIDDLE LAST( Use maiden name) BIRTH STATE
OTHER INFORMATION [] Pre arrangements [] DEATH: IS Imminent [] Has occurred DATE:__________
CORONERS OFFICE CALLED? [] NO [] Yes_TELEPHONE No.(_____)___________TIME_______________ LOCATION: [] AT HOME [] HOSPITAL / LOCATIONS: _______________________________________________________________________________________
County:_______________City:_________________ZIP: _________TELEPHONE No.(____ )_________
ATTENDING PHYSICIAN:___________________________________[] M.D. [] D.O. (____) _______
Address:_____________________________City:___________ ZIP:_____TELEPHONE No. (____ )____
____________________Fax &/or MEM #.______________________________:
WHAT TYPE OF SERVICES ARE YOU REQUESTING? #3
[] DIRECT CREMATION SERVICE [] ID REMAINS [] VIEWING
[] TRADITIONAL FUNERAL SERVICE [] MEMORIAL SERVICES [] OTHER _______________________
[] Cremated remains to SEA [] Cemetery: OR [] SHIP____________________________________
=================================================================
NOVA Cremation Service FD1396, 435 N. Echo , FRESNO, CA 93701 (559) 266 - 9400
B TO WHOM IT MAY CONCERN DATE:_____________________
THIS IS OFFICIAL NOTIFICATION FOR AUTHORIZATION TO RELEASE REMAINS.
NOVA CREMATION SERVICE has been Instructed to demand custody and take charge
for remains of: _______________________________________________ AUTHORIZED IS SIGNED BY
[] SELF []SPOUSE [] CHILD [] PARENT [] NEXT OF KIN and/or PERSON LEGALLY ENTITLES RIGHT TO CONTROL.
SIGNATURE: -:_________________________________________ _________________________
(AUTHORIZED REPRESENTATIVE) Witness signature
Print NAME: _________________________________________ _________________________
ADDRESS:__________________________________________
__________________________________________
=================================================================
NOVA Cremation Service 435 N. Echo, Fresno, CA 93701 ( 559 ) 266 - 9400
FOR MORE INFORMATION ON Funeral, Cemetery, and Cremation Matters;
CONTACT: Department of Consumer Affairs, Cemetery and Funeral Bureau,
1625 North Market Blvd., Suite S-208, Sacramento, CA95834 (800)952-5210
THIS IS AN EXAMPLE OF WHAT OTHER CHARGES MAY OCCUR Please REFER to our General Price List for COMPLETE LIST of charges and services. [SEE our WEB SITE, on General Price List].
Prices quoted to you MINIMUM BASE RATE ITEMIZED STATEMENT and our General Price list will be given.
INCLUDES *24-hour a day service [regardless DAY or NIGHT] *Arrangement service to meet your needs.
* Local transportation of remains. * Use of cold holding facility. *Preparation; securing legal documents.
* Local filing fee to health department. * Utility cremation carton with tax. * One certified copy of death certificate. *Durable holding container for cremated remains. * and INCLUDES the crematory cremation fee with CA Assessment fee . .FOR CREMATION, CASH RATE. . . . .$ 724.69
Additional personnel RE: home death call[ $75.00] (Ifapplicable) . . $ FAX &/or TELEPHONE FEES ADDITIONAL FEE TO FAX /CALL, LONG DISTANCE[$25.00] . . . $ ADDITIONAL NOVA FOR DECOMPOSING [$75.00] . . . . . . . $ OBESITY ADDITIONAL FEE DEPENDING WEIGHT #_____.[250 thru400] . . . . $ $ADDITIONAL MILEAGE and Nominal 2nd run to Physician, If applicableCity______ . . . $ URN, Copper Clad Sheet Metal ($_____ +tx. . . . . . . . . $ Different URN or other merchandise:_______________________________ . . . . $ Certified Death Certificate. Additional At $12.00 each...with 2nd cert . #___X= . . . $ Come to FRESNO to pick up cremated remains.. ; [] SHIP to youorCemetery$65.00 . . . $ IS THERE ANY FEE FROM CORONERS OFFICE ($_______?) OR MORE $_______ . . . . . $ THE Coroners office may want more than $100.00 for the purchase of ‘Body pouch. . . . $ Have elected to pay through Merchant card $_____ . . . . . . $ SUB TOTAL _______________ Scroll down for next page
#4 NOVA Cremation Service FD 1396 435 N. Echo, Fresno,CA 93701(559) 266-9400
and BELMONT MEMORIAL PARK 201 N. Teilman Ave., Fresno, CA 93706-1399(559)237-6185 FOR MORE INFORMATION ON Funeral, Cemetery, and Cremation Matters; CONTACT: Department of Consumer Affairs, Cemetery and Funeral Bureau, 1625 North Market Blvd., Suite S-208, Sacramento, CA 95834 (800)952-5210
AUTHORITY TO CREMATE AND ORDER FOR DISPOSITION
(In this document the word ‘I’ shall refer to all persons authorizing the cremation and disposition of the decedent)
I(We), the undersigned, “(the Authorizing Agent(s)”),hereby request and authorize. NOVA Cremation Service, (hereinafter referred to NOVA” and Belmont Memorial Park Crematory (hereinafter referred
to as the “Crematory”) to take possession of and make arrangements for the cremation of and the final disposition of the Decedent named below (the “Decedent”) in accordance with and subject to the provisions set forth on the front and reverse sides of this document,with and subject to rules and regulations, and any applicable state or local laws or regulations.
Name of Deceased:________________________________________________ Sex____ Age ____
Date of Death____________Time of Death__________Place of Death_________________________
Address of Deceased: ____________________________City___________________ State________ Mechanical, radioactive devices or implants in the Decedent may create a hazardous condition when placed in a cremation chamber. All pacemakers and radioactive implants must be removed prior to delivery of the decedent to the Crematory.
I/We understand that if the Funeral Home has NOT been notified about such devices OR implants and I/We have not instructed the removal of such devices or implants and I/We havw not instructed the removal of such items I/we are responsible for the $500.00 fee charged by the crematory for any explosion in the chamber due to a device not being removed. I/We also understand that if the damage exceeds this $500.00 fee. I/We are responsible for any additiobal costs to repair any damage to the Crematory or crematory personnel by such umplants or devices.
Do the Decedent’s remains contain any such devices? YES / NO - If yes,Please list devices prior cremation.__ I understand if NOVA not notified about such devices or implants, and not instructed to remove them, I/WE are responsible for any damages caused to Crematory or such personnel by such implants or devices. Name and relationship to Deceased__________________________ Signatures____________________________ CREMATION INFORMATION Unless otherwise indicated, the Crematory, or its authorized agents, is authorized to perform the cremation upon receipt of human remains, at its discretion, and according to its own time schedule as work permits, without obtaining any further authorizations or instructions. The human body burns with the casket, container, or other material in the cremation chamber. Some bone fragments are not combustible at the incineration temperature and as, a result, remains in the cremation chamber. During the cremation, the contents of the chamber may be moved to facilitate incineration. The chamber is composed of ceramic or other material which disintegrates slightly during each cremation and the product of that disintegration is commingled with the cremated remains. Nearly all the contents of the cremation chamber, consisting of the cremated remains, disintegrated chamber material, and small amount of residue from previous cremations, are removed together and crushed, pulverized, or ground to
facilitate inurnment or scattering. Some residue remains in the cracks and uneven places of the chamber.
Periodically, the accumulation of this residue is removed and interred in a dedicated cemetery property, or
scattered at sea. The Crematory requires either or an alternative (cremation) container for the cremation.
Please refer to page ‘D’ of the form for details regarding the casket/container. After the cremated remains have been processed, will be placed in designated urn or container. The Crematory will make a reasonable effort to put all of the cremated remains in the urn or container, with the exception of dust or other residue that may remain on the processing equipment.
AUTHORITY OF AUTHORIZING AGENTS(S) I/(We) hereby certify that the Decedent left the surviving heirs at law:
Spouse []Yes []No Name:______________________________________________________________
Children []Yes []No #____Name:_________________________________________________________
Parents []Yes []No Name:______________________________________________________________
Siblings []Yes [] No #____Name:______________________________________________________ Additional information may be attached. Disclosures, Warranties and permission (Initial each)
DECEASED ARRANGED FOR OWN CREMATION /PRE-NEED []Yes []No // Disposition instructions []Yes []No
DECEASED left Will instructions for cremation []Yes []No / Identified remains []Yes []No[] []not available
DECLARATION OF INTENT FOR DISPOSITION OF CREMATED REMAINS NOVA to arrange for the disposition of the cremated remains as per your instructions: Is there special handling required? []Yes [] No Describe ________________________________
[] Description of urn/container selected:______[] NOVA Durable/ Suitable for shipping [] Yes [] No
[] Deliver to Cemetery:_________________________________________________________
[] Release to family: ___________________________________________________________
[] Scattering at SEA provided by NOVA CREMATION SERVICE [] Scattering by other.
[] SHIP via U.S. Mail TO: REFER TO PAGE # 8 // NOVA CREMATION SERVICE and Crematory are not responsible for any loss or damage of cremated remains shipping via United States Postal service.
INITIAL ______ I/We authorize the Crematory to return the cremated remains of the possession and custody of NOVA . I (We) understand that the services and obligations of the Crematory shall be fulfilled when the cremated remains of the Decedent are returned to the possession and custody of NOVA.
Cremation Authorizing for page # A Scroll down for next page
# 5
NITIAL ______ I/We understand that if I wish to remove and/or retain any item from the remains,
I must do so directly or authorized agent prior to the transportation of the Decedent to the crematory.
INITIAL ______ I/We give full permission for the following: a) The incidental or inadvertent commingling of the cremated remains. b) The processing of the remains and resulting incidental commingling of the cremated remains. c) The disposal by the Crematory of metal or other non-human material recovered to
which may be affixed bone particles or other human residue.
INDEMNITY I/We declare under penalty of perjury that the foregoing certifications, representations and statements are true and correct and that this statement is being made to induce the above names Crematory to cremate (or cause to be cremated) the remains of the Decedent name above. I agree to hold harmless, indemnify and defend the above, named NOVA and crematory as well as their representatives, directors, officers, agents, employees and shareholders, from and against all claims, liabilities or damages whatsoever (including reasonable attorneys’ fee) which may result from this authorization and other including the failure to properly identify the remains, failure to take possession or make proper arrangements for the final disposition of the cremated remains, the processing of remains, shipping of remains, any explodable or harmful impact, infectious diseases, other persons claiming rights to
control disposition of the remains, or any other cause. No warranties, express or implied are made and damages shall be limited to the amount of the cremation fee paid. SIGNATURE OF AUTHORIZING AGENT(S) THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS IRREVERSIBLE AND FINAL. READ THIS ENTIRE DOCUMENT CAREFULLY BEFORE SIGNING.
I/WE THE UNDERSIGNED, hereby certify that I am the closet living next of kin of the Decedent or that I otherwise serve (served) in the capacity of ________________ to the Decedent, that I have charge of the remains of the Decedent and as such possess full legal authority and power to execute this authorization form and to arrange for the cremation and disposition of the cremated remains of the Decedent. In addition, I am aware of no objection to this cremation by any spouse, child, parent,
or sibling specified. By executing this cremation authorization form, as Authorizing Agent(s), the undersigned warrants that the undersigned have read and understand the provision contained of the front of this documents.
Executed at_______________this_____________day of ___________________________
NAME-: _______________________________ SIGNATURE:________________________________
Relationship to Decedent:__________________Phone No.__________________________________
Address:__________________________________________________________________________
City:_____________________________County:________________________State:____ZIP:______
NAME-: _______________________________ SIGNATURE:________________________________
Relationship to Decedent:__________________Phone No.__________________________________
Address:__________________________________________________________________________
City:_____________________________County:________________________State:____ZIP:______
NAME-: _______________________________ SIGNATURE:________________________________
Relationship to Decedent:__________________Phone No.__________________________________
Address:__________________________________________________________________________
City:_____________________________County:________________________State:____ZIP:______
Witness: X: ____________________________________ Cremation Authorizing for page #B
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# 6
REPRESENTATION OF FUNERAL DIRECTOR I warrant, to the best of my knowledge.: a) I have reviewed this form with the Authorizing Agent(s) and no member of our staff has any knowledge or information that would lead us to believe that any of the information stated on this Authorization by Authorizing Agent)s) is incorrect, b) that the human remains delivered to the Authorizing Agent(s); and c) NOVA has obtained all of the permits required for the cremation and disposition of the Decedent, and these permits are attached. I FURTHER WARRANT THAT ALL PACEMAKERS AND RADIOACTIVE IMPLANTS,
IF ANY, HAVE BEEN REMOVED FROM THE DECEDENT.
Signature of Funeral Director:-------------------------------------------------------------------
ADDITIONAL TERMS AND CONDITIONS***********THE CREMATION PROCESS
Cremation is performed to prepare the deceased for memorialization and it is carried out by placing the deceased in a casket or alternative container and then placing the casket or alternative container into a cremation chamber, or retort, where they are subjected to intense heat and flame. During the cremation process, it may be necessary to open the cremation chamber and reposition the deceased in order to facilitate a complete and thorough cremation. Through the use of suitable fuel, incineration of the container and its contents is accomplished by raising the temperature substantially (extreme temperature) and all substances are consumed or driven off, except bone fragments (calcium compounds) and metal (including dental gold and silver and other non-human materials) as the temperature is not sufficient to consume them.
Due to the nature of the cremation process, and personal possession or valuable materials such as dental gold and silver, or jewelry (as well as any body prostheses or dental bridgework) that are left with the Decedent and not removed from the casket or container prior to cremation may be destroyed and become
non-recoverable. If not destroyed, the Crematory is authorized to dispose of such material at its sole discretion.
THE AUTHORIZING AGENT UNDERSTANDS THAT ARRANGEMENTS MUST BE MADE WITH THE FUNERAL HOME [NOVA] TO REMOVE ANY SUCH POSSESSIONS OR VALUABLE PRIOR TO THE TIME
THAT THE DECEDENT IS TRANSPORTED TO THE CREMATORY.
Following a cooling period, the cremated remains, which will normally weigh several pounds in the case of an
average-size adult, are then swept or naked from the cremation chamber. The Crematory makes a reasonable effort to remove all of the cremated remains from the cremation chamber, but it is impossible to remove all of them, as some dust and other residue from the process are always left behind. In addition, while every reasonable effort will be made to avoid commingling, inadvertent or incidental commingling of minute particles of cremated remains from the residue of previous cremation is a possibility, and the authorizing Agent understands and accepts this fact.
After the cremated remains are removed from the cremation chamber, all non-combustible materials (insofar as possibly), such as dental bridgework, and materials from the casket or container, such as hinges, latches, nails, etc., will be separated and removed from the human bone fragments by visible or magnetic selection. The Crematory is authorized to dispose of these materials with similar materials from other cremations in a non-recoverable manner, so that only human bone fragments will remain.
When the cremated remains are removed from the cremation chamber, the skeletal remains often contains
recognizable bone fragments. After the bone fragments have been separated from the other material,
they will be mechanically process (pulverized). which includes crushing or grinding and incidental commingling of the remains with the residue from the processing of previously cremated remains, into granulated particles of unidentified dimensions, virtually unrecognizable as human remains, prior to placement into the designed container.
Cremation Authorizing for page #C
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#7
CASKET / CONTAINERS All caskets and alternative containers must meet the following standards:
1) Be composed of materials suitable for cremations;
2) Be able to be closed to provide a complete covering for the human remains;
3) Be sufficient for handling with ease;
4) Be resistance to leakage or spillage;
5) Be able to provide protection for the health and safety of crematory personnel.
The Crematory is authorized to inspect the casket or alternative container.
In the event there is leakage or damage, the Crematory may contact the
Authorizating Agent directly for instructions. For heath reasons, the Crematory’s personnel
will not open the container.
Many caskets that are comprised of combustible materials also contain some exterior
parts, e.g., decorative handles or rails, that are not combustible and that may
cause damage to the cremation equipment. The Crematory, at its sole discretion,
reserves the right to remove these non-combustible materials prior to cremation and to
discard them with similar materials from other cremations and other refuse in a non - recoverable manner.
URNS / TEMPORARY CONTAINERS In the event the urn or other container selected is insufficient to accommodate all the cremated remains, the excess will be placed in a separate receptacle. The separate receptacle will be kept with the primary receptacle and handled according to the disposition instructions on this form. Crematory requires that all urns or containers provided be appropriate for shipping or permanent storage, and that is the case of an adult, it is recommended that the urn or container be a minimum size of 200 cubic inches. Unless a suitable urn is provided for the cremated remains, the Crematory will be placed the cremated remains in a container furnished by the Crematory which is not designed for shipment.
FINAL DISPOSITION Cremation is NOT the final disposition, nor is placing the cremated remains at a funeral home final disposition. The cremation process simply reduces the decedent’s body to cremated remains. These cremated remains usually are several pounds and usually measures in excess of 150 cubic inches. Some provision must be made for the Final disposition of these cremated remains.
If the option selected for final disposition includes scattering, then the cremated remains will not be recoverable. If scattering is performed in a common area, then the cremated remains may be commingled with particles of other cremated remains that have been previous scattered.
NOTICE REGARDING CREMATED REMAINS
(1) FOR MORE INFORMATION ON Funeral, Cemetery, and Cremation Matters; CONTACT:
Department of Consumer Affairs, Cemetery and Funeral Bureau, 1625 North Market Blvd.,
Suite S-208, Sacramento, CA 95834 (800)952-5210
(2) A person having the right to control disposition of cremated remains may
remove the remains in a durable container from the place of cremation or
interment, pursuant to Section 7054.6 of Health and Safety Code.
(3) If the cremated remains container cannot accommodate all cremated remains
of the deceased, the crematory shall provide a larger cremated remains container
at no additional cost, or place the excess in a second container that cannot easily
come apart from the first, pursuant to Section 8345 of the Health and Safety Code.
Cremation Authorizing for page # D Scroll down for next page
State of CALIFORNIA - Consumer Affairs # 8
FOR MORE INFORMATION ON Funeral, Cemetery, and Cremation Matters;
CONTACT: Department of Consumer Affairs, Cemetery and Funeral Bureau,
1625 North Market Blvd., Suite S-208, Sacramento, CA 95834 (800)952-5210
DECLARATION FOR DISPOSITION OF CREMATED REMAINS
Pursuant to Business and Professions Code 7685.2
I/We hereby declare the remains of______________________________in the possession of
NOVA CREMATION SERVICE, Will be cremated by Belmont Memorial Park and shall be disposes of in the following manner:_____________________________________________________
Manner, Location, and Other details of disposition
ADDRESS:__________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
(If necessary, use separate sheet of paper to continue statement)
Name of Person(s) with the right to control disposition: [PRINT] _______________________
__________________________________________________________________________
Name of Person(s) contracting for cremation services: [PRINT]_________________________
____________________________________________________________________________
Signed -X:_____________________________________________ Date___________________
Person(s) with right to control disposition or self, if prearranging
Signed -X:____________________________________________ Date___________________
Person(s) arranging for cremation
Signed__________________________________ Lic.# FDR501 Date______________
Funeral Director’s signature
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NOVA CREMATION SERVICE # 9
435 N. Echo
FRESNO, CA 93701
(559) 266 - 9400
EXHIBIT 1
AUTHORIZATION FOR DISPOSITION WITH OR WITHOUT EMBALMING
TO: Nova Cremation Service
RE:_______________________________(Decedent) I,____________________________________
do___do not______(Check one) request embalming, which I understand is the additional to, or the replacement of, body fluids by chemical preservations or the application of chemical preservation for the temporary preservation of the body. I understand that embalming is NOT required by law.
I understand that for storage or embalming purposes may be transported to the following licensed funeral establishment:
NOVA Cremation Service, 435 N. Echo, Fresno, CA 93701
(Name and address of Funeral establishment)
The undersigned hereby represents that he/she has the legal right to control disposition of the remains of the decedent.
Signed X:-___________________________________Relationship:______________
Executed this day of ______________,________at city_____________, State______
To be Completed by Funeral Establishment if Authorization to embalm and Notification to
Transport to Obtain Orally (by telephone)
The above statement of authorization was read to__________________________________________
_____________________________________________, Relationship______________________________
Who did___ did NOT____ (check one) authorize embalming at the above named funeral establishment,
NOVA CREMATION SERVICE
City:_____________________State:__________________Phone: (________)___________________
Date and time authorization granted:____________/____________/_____________HRS:________
I, do___ do not_____ (check one) request embalming which I understand is for the temporary preservation of the body. I understand that embalming is NOT required by law.
Signature of Funeral Establishment representative accepting authorization.
I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.
Executed this________ day of______________, ________________________California
Signed:___________________________________________________________
Embalming Authorization & Release
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Disclosure of Preneed Funeral Agreement The Funeral establishment, #10
NOVA Cremation Service, (funeral establishment name) licensed number FD1396 , Does____, DOES NOT___ (check one) have a preened arrangement,
as defined below, made or on behalf of _______________________________________________. ( name of deceased )
If the funeral establishment does have a preened agreement, complete the following:
In compliance with Business and Professional; Code Section 7745. the funeral establishment
has presented to the person named below a copy of any preened agreement which has been
signed and paid for in full, or in part by, or the behalf of the deceased and is in the possession
of the funeral establishment.
___________________________________ _______________________________
Signature of funeral establishment representative Date
“Preneed arrangement,” “preneed agreement” or “preneed” is written instruction regarding goods or services or both goods and services for final disposition of human remains when the goods or serviced are not provided until the time of death, and may be either unfunded or pain for in advance of need.
Funeral Establishment’s Responsibility-,Business and Professional Code Section 7745 requires a funeral establishment to present to the survivor of the decedent or the responsible party a copy of any preened agreement in its possession which has been signed and paid for in full. or in part by, or on behalf of the deceased. Business and Professions Code Sections 7685.5 requires a copy of any preened arrangements to be disclosed prior to drafting any contract for funeral goods or service. The funeral establishment may present the copy in person, by certified mail, or by facsimile transmission, as agreed upon by the person with the right to control disposition. A funeral establishment that unknowingly fails to present a preened agreement as required is liable for a civil fine equal to three times the cost of preened agreement, or one thousand dollars ($1000.00) whichever is greater.
You may contact the Cemetery and Funeral Bureau for information on funeral, cemetery or cremation matters to file a complaint against a licensee:
Cemetery and Funeral Bureau
1625 North Market Blvd, suite S-208. Sacramento, CA 95834 (800)952-5210
-X_______________________________________________ ___________________
Signature of the survivor or responsible party Date
_________________________________________________
Print name of the survivor or responsible party
_______________________________________________ ________________________
Signature of funeral establishment representative Date
_____________________________________________ __________________________
Print name of funeral establishment representative Title
The funeral establishment must:
* Give a copy of the completed statement to the survivor or responsible party. * Retain the original or a copy of the completed disclosure statement on file for not less than
one (1) year after the preened account has been audited by the Bureau of Seven
(7) years from the date the disclosure statement was made, whichever comes first. 21Fi(10/03) Scroll down for next page
#11
NOVA CREMATION SERVICE (559) 266 - 9400
435 N. Echo , FRESNO, CA 93701
A promissory note - for FULL PAYMENT OF FUNERAL EXPENSES
A) I________________________________________________,the undersigned hereby certify
and represent MYSELF as the legal custdian(s) and hereby agrees accept legal obligation with all funds due regardless of intentions of any funds received or not. DO HEREBY PROMISE
TO PAY NOVA Cremation Service for Funeral Service Expenses of: _________________________________
______________________ who died on___________________ in______________________
B) I ACKNOWLEDGE that I received an itemized statement for Funeral Service expenses.
C) CONCERNING PAYMENT: YOUR INTENTIONS ARE,
Please decide as: NOTICE: Payment Prior service.
#1__ First class PRIORTY MAIL #2__ Regular postmaster service
#3__ OVERNIGHT EXPRESS #4__ Coming to FRESNO
NOTICE: If you elect to pay by
#5__ Mastercard / Visa / Discover
There is a different tiers. If you elect to use other than cash or checks, there will be an additional rate..
CARD NUMBER:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Expires_____________
I HAVE READ AND UNDERSTOOD THIS AGREEMENT AND AGREE TO PAY
NOVA Cremation Service AS AGREED. Date__________________ ALSO: Back of card CODE #________
SIGNATURE-:_____________________________________ Printed ___________________
Residence address:________________________________________________________________
_______________________________________________________________________________
Telephone: Home:(______ )____________________ WORK: (______)_____________________
Driver’s license or ID Card NO:______________________________________________________
Do you OWN your Own home? ; yes ; No Employment INFO:_______________
Automobile_____________________ _____________________________
IF YOU ARE making arrangement Via MAIL or FAX.
YOU MUST PROVIDE A COPY OF IDENTIFICATION.
Be sure to send a copy with photo and signature such as a driver’s license.
When FAXing, FOR RETURN FAX,
CALL (559) 2 6 6 - 9 4 4 0
Home telephone, PLEASE CALL FIRST
NOVA CREMATION SERVICE: A FULL SERVICE Funeral establishment.
DAVID Wm. LOPER FD 1396. FDR 501 . Emb. 6135
Notice: If you are unsure or do not understand, PLEASE call.
THANK YOU /////
and #12 Do not forget your ID COPY
