Authorization for Cremation of Fetal Tissue (Blank) (00225756)

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

1 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