Attach a file(jpeg, png)
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 Vault Transfer.
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.
I hereby agree to the terms and conditions and consent to the collection, use and
disclosure of all personal information I have provided hereunder for the purpose of Golden Haven
services rendered and all other documents related hereto.