Authorization Funeral Form – Fill Out and Use This PDF

Texas Funeral Service Commission Form 10.1.01b

AUTHORIZATION TO EMBALM AT FUNERAL

ESTABLISHMENT OR OTHER LOCATION

Name of Licensed Funeral Establishment ___________________________________

Name of Deceased________________________________Date of Death____________

The undersigned, understanding that embalming is not required by law except in certain special cases, authorizes the funeral establishment to utilize a licensed facility under the same general ownership and management or use licensed embalmers as agents or independent contractors or a commercial embalming establishment to care for, embalm, and prepare the body of the deceased. The funeral establishment accepts the responsibility of revealing, upon request, to the next-of-kin or person responsible for making final disposition arrangements, the name, address, and license number of the facility where embalming occurred and the name and license number of the embalmer and any provisional licensee or mortuary student who assisted under the embalmer’s direct supervision. The undersigned authorizes and directs the funeral establishment, including apprentices (provisional licensees), and mortuary students under the direct supervision of a licensed embalmer employed by the funeral establishment, and the funeral establishment’s employees, independent contractors, and agents to care for, embalm and prepare the body of the decedent. The undersigned acknowledges that this authorization encompasses permission to embalm at the funeral establishment or at another facility equipped for embalming, including a school or college of mortuary science.

________________________________________________Date Signed_____________

Signature of next-of-kin or Person Responsible for making arrangements for final disposition

NOTE: Mortuary Students may only participate in embalming if permission is in writing and in the possession of the Licensed Embalmer at the time of the procedure.

If Authorization for embalming is oral, complete the following:

Location of embalming disclosure was discussed with next-of-kin or person responsible for making arrangements.

Authorization to embalm received from ___________________________________________________

Relationship to Deceased________________________________________________________________

Time____________________________a.m. or p.m. Date____________________________________

Received by___________________________________________________________________________

If no authorization can be obtained, complete the following:

I hereby acknowledge that _________________________________ has made a reasonable effort over a

Name of Establishment

period of at least three hours to obtain authorization to embalm the deceased. I take full responsibility for

performing embalming without permission.	Times contact with family attempted: ______________
	______________
___________________________________	______________
Signature and License # of Embalmer

The undersigned, who represents the deceased, hereby declares that having the legal authority to do so, refuses to give permission to embalm the above-named deceased individual. ____________________________________________________________________

Signature

Date