Customer Designation of Intention

N.Y.C. Funeral + Cremation Service Inc.

800-969-6602

"customers designation of intentions"

(Please fill out all fields highlighted in yellow only!)

Name of Deceased

Cremation scheduled date location of cremation

Manner of disposition of cremains

Burial at

Entombment at

Return to Family

I hereby designate the disposition of cremains and acknowledge receipt of a copy of this form

Signature

Print name

relationship

Address

"Cremains which shall not have been claimed within 120 days from the date of cremation may be disposed of by this firm in the following manner of disposition - scatter at sea

Name of Funeral Director
Signature of Funeral Director

TO BE COMPLETED FOLOWING CREMATION AND DISPOSITION OF REMAINS

Cremation (actual date) Location of Crematory

Manner of Disposition
Name of person making disposition
Signature date

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Signature