I hereby authorize "Ashes in Paradise" to provide the ash scattering service of the following deceased person: 

Legal Name of Deceased: _____________________________________________

Date of Birth _______________  Date of Death ________________  M/F ________

Name of Crematory & Permit # _________________________________________

I request the ash scattering to be performed within 30 days of receipt of these remains, weather permitting, off the shores of the Big Island of Hawaii.  I fully understand that the cremated remains are not recoverable once the scattering service has been performed. 

I authorize "Ashes in Paradise" to dispose of the container labeled "cremated remains" at their sole discretion, unless specifically requested otherwise in a separate letter attached to this authorization form.

I will hold harmless "Ashes in Paradise" and its employees of authorized representatives from any and all loss, damage liability, or causes of action ( including all attorney and litigation expenses) in connection with the disposition of the cremated remains of the above named deceased.  "Ashes in Paradise" is not responsible for any loss or damage caused by any third party.  Any liability of "Ashes in Paradise" shall be limited to the costs of the scattering service provided.

I hereby certify that I have full legal control of the disposition decisions of the above named deceased. 

___________________________           __________
Signature                                                       Date

___________________________            _____________________________
Print Name                                                      Relationship to Deceased

___________________________            _____________________________
Legal Name of Deceased                              Social Security # of Deceased

________________________________ _____________________________
Funeral Director & Permit Number ...or... Crematory & Permit Number