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N.Y.C. Funeral + Cremation Service Inc.
APPLICATION FOR CREMATION PERMIT

Form Must Be Notarized
(Print this form and Sign at the notary. Then Scan and email to: nycfuneraldirector@gmail.com or FAX 800-376-7401) (Please fill out all fields highlighted in yellow only!)
(As an alternative to going out to get this notary form signed, this form can now be signed online without leaving the comfort of your home. - https://www.onlinenotary.net )

State of

COUNTY OF.............} ss:

Being duly sworn deposes and
says that he* / she* resides at and desires that a permit be issued by the Department of Health and Mental Hygiene of the State of New York for the cremation of the body of who died at on Deponent's assumption of authority to act is based upon the following:

 

Deponent further states that the deceased [DID]*/ did not* express during life the desire to have his* / her* remains cremated and his* / her* relationship to deceased is

Deponent assumes all responsibility for the cremation of the remains and authorizes

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

, a licensed funeral director/ Funeral Home to make arrangements for said disposal.

Subscribed and sworn to before me this

day of
Next of Kin Sign Here
Familia Firmar Aqui
*Cross out words that do not apply.

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