The undersigned authorizes SANDY CREEK CREMATION AND MONUMENT COMPANY, herein after referred to as “‘crematory” in accordance with and subject to its rules and regulations to cremate who passed away on at   in the (City/Borough/Township) of in the county of : in the state of   who's age race and sex   have been disclosed. In addition, the undersigned agrees to be responsible and pay for all charges incurred due to this authorization to the funeral home / director herein listed Mark Noll 

Was death due to an infectious or contagious disease? YesNo

If yes, please explain It is further understood that if I do not notify the crematory about such manner of death, the liability of any damages to the crematory and/or its owners and employees becomes my responsibility.

Pacemaker? YesNo

Radioactive Implant? YesNo

Prosthesis? YesNo

Silicone Implant? YesNo

Any other life-sustaining device? YesNo

If you have selected yes at any time above, you further state that you have notified the funeral home or funeral director to remove the device(s) before cremation, you also agree that in the event you have failed to notify the funeral home, funeral director, or crematory, any damages to the crematory or its owners and / or-employees will become your liability.

Final Disposition: It is the expressed desire of the undersigned in agreement with the above mentioned funeral home that the cremated remains will be handled as follows:

I hereby certify that I represent the deceased as and that I am the closest living next of kin to the decedent and that I have the legal right to authorize this cremation and the disposition of the cremated remains. I also understand the cremation process and all that is involved herein. I am also aware that any time during the process of arrangements I had the ability to inquired about this process and ask any questions of the above mentioned funeral home. I further agree I will hold harmless the crematory, and / or funeral home or director, their officers, employees, and agents from any liability, costs, or claims, bound by his authorization with the exception only of acts of willful negligence.

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Signed by Mark Noll
Signed On: September 29, 2021

Signature Certificate

Document name: Authorization for Cremation and Disposition

Unique Document ID: 4599f596c57e918847d6c2737b99d813171f7654

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Timestamp	Audit
February 13, 2021 12:19 PM EDT	Authorization for Cremation and Disposition Uploaded by Mark Noll - mark@nollfuneral.com IP 71.112.184.38
July 15, 2021 10:06 AM EDT	pat rodgers - patrick@rodgersengineering.com added by Mark Noll - patrick@rodgersengineering.com as a CC'd Recipient Ip: 73.79.25.66
July 15, 2021 10:10 AM EDT	Mark Noll - mark@nollfuneral.com added by Mark Noll - patrick@rodgersengineering.com as a CC'd Recipient Ip: 73.79.25.66
September 29, 2021 11:42 AM EDT	Mark Noll - mark@nollfuneral.com added by Mark Noll - mark@nollfuneral.com as a CC'd Recipient Ip: 71.112.184.38

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https://nollfuneral.com/

Audit Trail Serial# 0feeb1b57dd19fdf722d743e59222346