Heavenís Wings
1634 Golden Gate Avenue
P.O. Box 155
Dos Palos, CA 93620
Ph.(209) 392-3165 Fax (209) 392-6833


Legal Name of Deceased: _________________________________
SS # _____ ó ___ ó _______
Date of Birth : ____________________________
Date of Death : ____________________________
Date of Cremation : ________________________
Funeral Director : ________________ Permit Number :____________
Crematory : ________________________ Permit Number: ____________

Scattering to be conducted as follows: ____________________________________________________________________

THIS IS TO CERTIFY THAT I am the person responsible for and having full legal control of the disposition of the remains of the deceased person named above. I hereby authorize Heavenís Wings to take possession of and scatter by air within 30 days of receipt of these remains from me weather permitting. I agree to hold harmless and indemnify Heavenís Wings and its authorized representatives from claims, demands, or damages which may arise from misrepresentation of remains to Heavenís Wings or loss by any airline, common carrier, or mail or parcel service engaged by applicant or his/her representative (s) for transportation of remains to Heavenís Wings. All efforts will be made to secure, safeguard, and scatter these remains exactly as requested, however Heavenís Wings shall not be responsible for theft, acts of god, or circumstances beyond our control. Any claims for loss or damage against Heavenís Wings shall be limited to the costs of the scattering ceremony.

Date: _______________

Name of applicant: ________________________________________

signature: _________________________________________________

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