This form gives permission to transfer the deceased from the place of death to our facility.

Release and Financial Responsibility Form

This form gives permission to transfer the deceased from the place of death to our facility.

LinkedIn
This field is for validation purposes and should be left unchanged.
Name of Deceased*
First Middle Last
Place of Death: Residential Address or Name of Facility*
Name of Person Authorized to Release*
Relationship to Deceased*
Address of Person Authorize to Release*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Telephone Number of Person Authorized to Release*
Social Services
- I/We intend to apply for welfare
I, the undersigned, hereby authorize and give permission to the Cremation Society of New Hampshire or their designated agent to transfer the deceased from the place of death to their facility. I further authorize that I have the legal authority to make this decision. I acknowledge that I have read the Social Service Policy on Financial Assistance and agree to go to the welfare office in the city or town where the deceased resided in a timely fashion in order to request financial assistance. I understand that the Cremation Society offers a discount fee to welfare departments of $1,100 to cover the cost of a direct cremation and agree that if the welfare office pays less than $1,100, I will be responsible for the difference. I further agree that if welfare assistance is denied or otherwise not provided, I take financial responsibility to pay the full price of the cremation.
Credit Card Information
Please enter your credit card information. Your card will NOT be charged at this time upon submission of the form.
Card Holder Name
First Last
Credit Card Number
Expiration Date
CVV/CSV Code
Electronic Signature:
(In accordance with RSA 294-D New Hampshire Digital Signature Act)
I, the undersigned, hereby authorize and give permission to the Cremation Society of New Hampshire or their designated agent to transfer the deceased from the place of death to their facility. I further authorize that I have the legal authority to make this decision and accept full financial responsibility for paying for the cremation. I acknowledge that I am providing a credit card number only to secure services, and that my credit card will not be charged prior to speaking with a cremation counselor regarding my preferred payment method. If I fail to proceed with cremation arrangements in a timely fashion, or refuse to communicate with my cremation counselor, I authorize this card to be charged for the full amount of services rendered.

By signing this form, I hereby acknowledge that a General Price List (GPL) has been made available to me either online or in-person and have I reviewed the GPL. Upon payment, the Cremation Society of New Hampshire agrees to provide the purchaser a Statement of Goods and Services either electronically or in person as soon as feasibly possible.
Full legal name of member or individual authorized to make cremation arrangements:*
Electronic signature confirmation:*

Don’t be scared. We have a guide for you:

Celebrate Your Loved One

Don’t feel overwhelmed. We offer flexible payment options:

Subscribe to our Newsletters

Release and Financial Responsibility Form

Electronic Signature: