Except as otherwise provided in Health and Safety Code section 7304, human remains shall not be embalmed without the express authorization of a person having the legal right to control disposition of the remains. Such authorization, to either accept or decline embalming, shall be secured by use of form 12-AUTH (rev. 11/14) prescribed by the bureau and made a part of this regulation. The form shall be used in the exact form set forth below, without additions, substitutions, or amendments, and may be either a separate form or combined with another form.

AUTHORIZATION TO ACCEPT OR DECLINE EMBALMING

TO: _____________________________________________

(Funeral Establishment Name)

RE: ________________________________________

(Decedent)

Embalming is the addition to, or the replacement of, body fluids by chemical preservatives or the application of chemical preservatives for the temporary preservation of the body. I understand that embalming is not required by law.

I, ______________________________, do ___ do not ___ (check one) request embalming.

I understand that for storage or embalming purposes the decedent may be transported to the following location:

(Location Name and Address)

The undersigned hereby represents that he/she has the legal right to control disposition of the remains of the decedent.

Executed this __________ day of ____________________(Month), __________(Year),

at ________________________________________ (City and State)

This section is to be completed by the funeral establishment if authorization to accept or decline embalming is obtained orally.

The above statement regarding embalming and storage was read and/or provided to _________________________, Relationship to Decendent: ____________________, who did ___ did not ___ (check one) authorize embalming at the above named funeral establishment.

Telephone Number: _________________________

This section is to be completed by the funeral establishment representative who is executing this authorization to accept or decline embalming.

I declare under penalty of perjury that the foregoing is true and correct. Executed this __________ day of ____________________(Month), _____(Year),

at ________________________________________ (City and State)

(Funeral Establishment Representative (Print Name)

Funeral Establishment Representative (Signature)

12-AUTH (rev. 11/14)