AUTHORIZATION FOR CREMATION OF FETAL TISSUE ­­­­­­­­­­­­­­ Of

authorization for cremation of fetal tissue ­­­­­­­­­­­­­­_________________________________________, of ___________________, maine (the “au

AUTHORIZATION FOR CREMATION OF FETAL TISSUE
­­­­­­­­­­­­­­_________________________________________, of
___________________, Maine (the “Authorizing Entity”) hereby
authorizes and requests PINE GROVE CREMATORIUM, a Maine non-profit
corporation, in accordance with and subject to its rules and
regulations and any applicable state or local laws or regulations, to
cremate the following fetal tissue under 20 weeks of gestation,
identified as:
(Name or
identification):________________________________________________________
And to return the cremated remains of the fetal tissue to the
Authorizing Entity.
Disclosure of the Cremation Process
The cremation, processing and disposition of the fetal tissue will be
performed in accordance with Title 32 of the Maine Revised Statutes
Annotated, Section 1405, as may be amended from time to time, and any
applicable regulations or ordinances. Cremation of the fetal tissue
will be performed by placing all of the above-described fetal tissue
in a cremation container and then placing the container into a
cremation chamber or retort where it will be subjected to intense heat
and flame. Fetal tissue will be comingled and cremated together and
not individually. Through the use of natural gas, incineration of the
container and its contents is accomplished and all substances are
consumed, except bone fragments (calcium compounds) as the temperature
is not sufficient to consume them. Following the cooling period, the
cremated remains will be swept or raked from the retort. Pine Grove
Crematorium makes every reasonable effort to remove all of the
cremated remains from the retort, but it is impossible to remove all
of them, as some dust and other residue from the process is always
left behind. After the cremated remains are taken from the retort,
they are mechanically processed (pulverized). This process of crushing
or grinding may cause incidental comingling of the remains with
residue coming from the processing of previously cremated remains.
These granulated particles will be virtually unrecognizable as fetal
tissue remains.
Fetal Tissue Under 20 Weeks of Gestation
The Authorizing Entity certifies that the above-identified fetal
tissue is under 20 weeks of gestation and that no certificate of death
exists or was filed in connection with the above-identified fetal
tissue.
Authority of the Authorizing Entity To Authorize Cremation
The Authorizing Entity certifies that it has legal custody of the
herein-identified fetal tissue resulting from either the direct
donative transfer to the Authorizing Entity from the closest living
kin of the fetal tissue or from the transfer of the tissue from a
hospital or medical facility, for research, scientific or educational
purposes and that such use is no longer practical, viable or necessary
and the Authorizing Entity desires to dispose of the fetal tissue
through cremation. The Authorizing Entity certifies that it is under
no obligation, legal, ethical or otherwise, to return the fetal tissue
to its closest living kin or the source from whence the Authorizing
Entity acquired the fetal tissue and that the Authorizing Entity
possess full legal authority and power, according to the laws of the
State of Maine, to execute this authorization form and arrange for the
cremation and disposition of the cremated remains of the
above-identified fetal tissue. The Authorizing Entity is aware of no
objection to this cremation by the living kin of any of the
above-identified fetal tissue.
Limitation of Liability
The Authorizing Entity hereby agrees to indemnify, defend, and hold
harmless Pine Grove Crematorium, its directors, officers, agents,
employees and representatives, of and from, any and all claims,
demands, causes or causes of action, and suits of every kind in law or
equity, including legal fees, costs and expenses of litigation,
arising as a result of, based upon, or connected with this
authorization, including, but not limited to, the arrangement of
cremation, cremation of the fetal tissue; any claims brought by any
other person(s) claiming the right to control the disposition of the
fetal tissue or the cremated remains of the fetal tissue; excepting
only acts of willful negligence.
By executing this Authorization For Cremation of Fetal Tissue, the
Authorizing Entity warrants that all representations and statements
contained herein are true and correct and that these statements are
made to induce Pine Grove Crematorium to cremate the herein-identified
fetal tissue.
Dated at Bangor, Maine this ___ day of _______________, 20___.
____________________________
(Authorizing Entity)
_____________________________ By: ____________________________
Witness Name:
Its:
Hereunto Duly Authorized
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