Section A   Disposition
Application is hereby made with the Sperry & McHoul Funeral Service to arrange removal after death and to proceed with the cremation of:

______________________________________________             ________________
(name of applicant)                                                                          (date)

The disposition of the cremated remains will be:
____  Family will pickup at our office*
____  Scatter at sea
____  Mailing
____  Funeral home to arrange and deliver to cemetery
____  Other (please specify)

          _______________________________________________________________

Section B    Payment options
I understand that all fees herewith connected are to be paid in full when the services are rendered and I so charge the responsible survivor accordingly with this obligation.

Signature of applicant   __________________________________________________

I am paying at this time:
____  $25 registration and filing fee
____  In Full: A trust in applicants name to be set up with Sperry & McHoul. Payment must accompany this application in order that it be binding.

Section C    Authorization
Application has been made with the Sperry & McHoul Funeral Service to care for said body after death. This statement will constitute authority to remove said body from whatever facility has custody at the time of death and proceed with the cremation. I (we) hereby represent that I am (we are) of the same and nearest degree of relationship to the above named and/or are legally authorized or charged with the responsibility for such cremation and/or other disposition.

Signature(s)   ___________________________________ Relationship _____________

                     ___________________________________                       _____________

                     ___________________________________                       _____________

Section D    For families who wish to pickup cremated remains at our office
Storage and disposition:
I hereby authorize disposal (funeral home's option of burial or scattering at sea) in the event that I have not called for the cremated remains within sixty (60) days of cremation at the discretion of Sperry & McHoul Funeral Service, and release any liability for this performance. I shall assume responsibility for the minimal cost of the final disposition as listed on the price list of Sperry & McHoul Funeral Service.

Signature _____________________________________ Relationship ______________