Texas Funeral Service Commission Form 10.1.01b

 

AUTHORIZATION TO EMBALM AT FUNERAL ESTABLISHMENT OR OTHER LOCATION

 

Name of Licensed Funeral Establishment: 

Name of Decease:  Date of Death: 

The undersigned, understanding that embalming is not required by the law except in certain special cases, authorizes the funeral establishment to utilize a licensed facility under the same general ownership and management or use licensed embalmers as agents or independent contractors or a commercial embalming establishment to care for, embalm, and prepare the body of the deceased.

The funeral establishment accepts the responsibility of revealing, upon request, to the next-of-kin or person responsible for making final disposition arrangements, the name, address, and license number of the facility where embalming occurred and the name and license number of the embalmer and any provisional licensee or mortuary student who assisted under the embalmer’s direct supervision. The undersigned authorizes and directs the funeral establishment, including apprentices (provisional licensees), and mortuary students under the direct supervision of a licensed embalmer employed by the funeral establishment, and the funeral establishment’s employees, independent contractors, and agents to care for, embalm and prepare the body of the decedent. The undersigned acknowledges that this authorization encompasses permission to embalm at the funeral establishment or at another facility equipped for embalming, including a school or college or mortuary science.

 

NOTE:   Mortuary Students may only participate in embalming if permission is in writing and in the possession of the Licensed Embalmer at the time of the procedure.

 


Signature of next-of-kin or Person Responsible for making arrangements for final disposition:  

Dated Signed:October 5, 2022

 

If Authorization for embalming is oral, complete the following:

Location of embalming disclosure was discussed with next-of-kin or person responsible for making arrangements.

Authorization to embalm received from:

Relationship to the Deceased:  

Time:    Date:  

Received by:

 

If no authorization can be obtained, complete the following:

I hereby acknowledge that:  has made a reasonable effort over period of at least three hours to obtain authorization to embalm the deceased. I take full responsibility for performing embalming without permission.

 

Times contact with the family attempted:

 


   
Signature and License # of Embalmer

 

The undersigned, who represents the deceased, hereby declares that having the legal authority to do so, refused to give permission to embalm the above-named deceased individual.

 

Signature:

Date Signed: October 5, 2022

 

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Signature Certificate
Document name: Authorization to Embalm at Funeral Establishment
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Timestamp Audit
March 22, 2022 10:47 pm CDTAuthorization to Embalm at Funeral Establishment Uploaded by Brandon Lee - bayne@baynedm.com IP 112.210.232.114
March 22, 2022 10:50 pm CDTCrystal Mccoy - crystal@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53
March 22, 2022 10:50 pm CDTBrandon Lee - brandon@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53
March 22, 2022 11:12 pm CDTCrystal Mccoy - crystal@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53
March 22, 2022 11:12 pm CDTBrandon Lee - brandon@mccoyandharrison.com added by Brandon Lee - bayne@baynedm.com as a CC'd Recipient Ip: 112.210.228.53