I hereby certify that I am the
of the above mentioned decedent of the above-named decedent and that this is your authority to make
disposition of the decedent as above indicated.
I hereby certify that I have the right to make this authorization, and I agree to hold GOLDEN HAVEN
MEMORIAL PARK, INC. free from any liability on account of said Exhumation.
I hereby certify that I am the owner of the above-described property and I hereby authorized the above
re-interment and placement of a marker thereon and agree to the above instruction and authorization.