AUTHORIZATION

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I hereby designate Southview Mortuary to take charge of funeral arrangements for:

and I authorize the release and removal of the remains to said funeral establishment for the purpose of embalming.

I represent that I am the next of kin, and or am acting as an authorized agent for the next of kin.

and I authorize the release and removal of the remains to said funeral establishment for the purpose of embalming. I represent that I am the next of kin, and or am acting as an authorized agent for the next of kin.

Signed:

Clear Signature

Relationship:

Co-Sign Name:

Co-Signed:

Clear Signature

Relationship:

Witness:

Date:

For Verbal (Telephone) Authorization:

Authorization from:

Relationship:

Date / Time:

Date

Time

Received By: