PURSE FUNERAL HOME Michigan's Finest U-2005

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1 -^ w-. -_--_- FUNERAL DIRECTORS -g- Jss Michigan's Finest U-2005 IMPORTANT INFORMATION Please Read Carefully NOTICE: This document has been prepared to assure that the person(s) contracting cremation or funeral services from J. Gilbert Purse FH and Family (MichiganFuneralHome.com) understands and agrees to the information below. *1.) It takes no less than 3 to 7 business days, sometimes longer, to complete the cremation process. The time starts on the first business day after receiving our completed and signed forms from the family. The first step in the process is the doctor signing the death certificate. We have no control over the doctor who is to sign the death certificate. After the death certificate is signed a permit has to be requested from the county medical examiner for the cremation. It can take up to 2 days to receive this permit. We have no control over the county medical examiner. We highly recommend if you are planning to have a memorial service and want your loved ones ashes present for that service, that you do not make plans for that service UNTIL you have received the ashes. We cannot make any guarantees as to when the ashes will be ready for pickup or delivered by the USPS Priority Express Delivery. *2.) All Death Certificates ordered through our funeral home from the county / city clerk will be done via UPS Express & USPS Priority Mail. A USPS Priority Mail postage fee of $5.00 for tracking purposes will be added to the cost of death certificates ordered. Please note, that if you are requesting the certified death certificates ASAP, we recommend that you purchase them directly from the clerk's office, not through our funeral home because we have no control over UPS or the USPS and cannot guarantee when you will receive the certified death certificates in the mail. *3.) Personal Effects J. Gilbert Purse Funeral Home accepts no responsibility for any personal effects that are given to us by a third party (hospital, nursing home, medical examiner, etc.). Personal Effects may have been transferred to our funeral home with your loved one. (for example: clothes, jewelry, etc...) If we are in possession of any personal effects we will return them to you if you wish. (Please note shipping costs will apply for larger items that are unable to ship with the cremains) PLEASE INITIAL* Property: Dispose of Effects: Cremate with Decedent: List Items to be returned (If present) ' Tecumseh, MI 49286

2 Vk -M-I -w-r FUNERAL DIRECTORS gg- Michigan's Finest FAX COMPLETED DOCUMENTS TO FAX # GENERAL RELEASE FORM Date: To Whom It May Concern Please release the decedent: TO: J. GILBERT S 210 W. Pottawatamie Tecumseh, MI N. Adrian Hwy WWW. PURSEFUNERALHOME. COM Signed: Printed: Relationship: Phone: Tecumseh, MI 49286

3 AUTHORIZATION FOR CREMATION Tri County Cremation Services 1106 E. Michigan Ave Date Ypsilanti, Michigan (734) Funeral Home J. Gilbert Purse FAX (517) Adrian, MI FAX (517) Tecumseh,MI Cremation No FAX COMPLETED DOCUMENTS TO FAX # J. Gilbert Purse Funeral Home The undersigned, does hereby authorize and request Tri-County Cremation Services in accordance with and subject to its rules and regulations, to cremate the remains of who passed away at on the date of,of the following cause and was born on the date of _. I, _ have positively identified the said remains or papers attached. (Please Print Name of Signer) The undersigned, further certifies and represents that he or she has the right to authorized cremation and that the consent of no other person is necessary for this order, and agrees to hold said Crematory and J. Gilbert Purse Funeral Home harmless from any liability on account of said authorization and cremation. The undersigned, further agrees to pick up the cremains from the Funeral Director, or make arrangements for their final resting place within (30) THIRTY days. Pacemaker: YES Nc ALL PACEMAKERS MUST BE REMOVED Cremation Casket: CARDBOARD CASKET (INCLUDED in our direct cremation price) PLYWOOD CASKET (REQUIRED for Decedent 300 LBS plus / Additional $95) J. GILBERT PURSE F. H. & TRI COUNTY CREMATORY ACCEPTS NO RESPONSIBILITY FOR ANY PERSONAL EFFECTS OR JEWELRY THAT ARE LEFT WITH THE DECEDENT FOLLOWING GIVEN PERMISSION TO TRANSPORT DECEDENT FOR CREMATION. ALL EFFECTS OR JEWELRY NOT REMOVED BY THE FAMILY BEFORE OUR TRANSPORT WILL BE ASSUMED TO BE CREMATED ALONG WITH THE DECEDENT. Signature of Next of Kin (Authorized Signer)_X _ Relationship: Address City _ State _ Phone Funeral Director Gary Purse Phone This authorization, fully signed and completed, must accompany casketed remains (excluding a plastic casket), and be delivered to the Tri-County Cremation Services together with a Board of Health, Burial Transit or other appropriate permit, before cremation can be performed. Date Cremated Please ship cremains to (If other than Funeral Home): Operator J. Gilbert Purse Cremains Returned: Date Received by: Via Date

4 Michigan's Finest J.GILBERT COM FAX COMPLETED DOCUMENTS TO: FAX # (517) DEATH CERTIFICATE INFORMATION FORM FUNERAL DIRECTORS Barry Purse Gil Purse Gary Purse frank Lennox NAME: first middle last C (maiden name) DATE OF BIRTH: SEX: SSN: OCCUPATION (before retirement)_ INDUSTRY: CURRENT ADDRESS: COUNTY: TOWNSHIP: CITY & STATE OF BIRTH: MARITAL STATUS (married, widow, divorced, nev. married): VETERAN?: SPOUSE'S NAME (Maiden name if applicable): ANCESTRY (i.e. French, Polish, Irish, English, Italian): RACE: HISPANIC? LEVEL OF EDUCATION: FATHER'S NAME: MOTHER'S NAME (include maiden): NAME & ADDRESS OF NEXT OF KIN (please list below) RELATIONSHIP TELEPHONE DISPOSITION OF CREMATED REMAINS ( please check one): return to party listed above by USPS Priority Express ($30) will make arrangements to pick up at J. Gilbert Purse Funeral Home in Adrian, MI will make arrangements to pick up at: (circle one) Crematory in Ypsilanti, MI / Crematory in Taylor, MI Adrian Chapel 2959 N. Adrian Hwy. (M-52) Manager / Gary Purse When Calling Long Distance, Please use our 800 number FAX Tecumseh Chapel 210 W. Pottawatamie St. Tecumseh, MI Manager / Barry Purse

5 Vk -»-i -m-m- FUNERAL DIRECTORS Michigan's Finest 1* CREDIT CARD AUTHORIZATION I,, hereby authorize the J. Gilbert Purse Funeral Home (MichiganFuneralHome.com) to process the following credit card: Visa MasterCard Discover American Express CARD NUMBER EXPIRATION DATE SECURITY CODE ON BACK PHONE NUMBER NAME OF CARD HOLDER ADDRESS FOR A PAID RECEIPT Cremation / Funeral Services for: This card is to be used for the following: Please note cash advance items such as newspapers notices & etc. will receive a five percent (5%) cash advance convenience fee when paying by credit card. Signature & Date FAX COMPLETED FORM TO: Tecumseh, MI 49286