Aquamation Authorization

NORTH CAROLINA BOARD OF FUNERAL SERVICE

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STANDARD ALKALINE HYDROLYSIS AUTHORIZATION FORM

NOTICE: THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING ALKALINE HYDROLYSIS. THE PROCESS IS IRREVERSIBLE AND FINAL. READ THIS DOCUMENT CAREFULLY BEFORE SIGNING.

Name of Individual for which alkaline hydrolysis is being arranged*

(hereinafter referred to as “Decedent”)

Date of Birth

Date of Death

Time of Death

Age

Place of Death

Hospice

Yes

Medical Examiner’s Authorization Required

Yes

Death Due to an Infectious Disease

Yes

Name of Individual Confirming Identity of Decedent*

Signature*

A. The undersigned (hereinafter referred to as "Authorizing Agent{s}”) hereby certify, warrant, and represent that I/we have the full legal right and authority to authorize and arrange for the alkaline hydrolysis (hereinafter “hydrolysis”) and final disposition of*

(hereinafter referred to as "Decedent"); Authorizing Agent(s) is (are) not aware of any living person who has a superior right to that of Authorizing Agent(s) as set forth in G.S. 90-210.124; or, if there is another living person who does have a superior right to that of Authorizing Agent(s), Authorizing Agent(s) represent that Authorizing Agent(s) has (have) made all reasonable efforts to contact such person, has (have) been unable to do so, and has (have) no reason to believe that such person(s) would object to the alkaline hydrolyzation of Decedent.

Name(s) of person(s) attempted to be contacted:

B. If Authorizing Agent(s) is/are aware of any other living person(s) with equal right to that of Authorizing Agent(s), Authorizing Agent(s) hereby certify, warrant, and represent that Authorizing Agent(s) has (have) either disclosed the location of all living persons with equal right to that of Authorizing Agent(s), as set forth in G.S. 90-210.124, or does (do) not know the location of any other living person with an equal right to that of AuthorizingAgent(s).

C. If Decedent’s hydrolysis involves a licensed funeral establishment or individual licensed pursuant to G.S. 90-210.25(a2)(2):

I/We hereby authorize:*

(hereinafter referred to as “Hydrolysis Licensee”)

whose address is:

to take possession of Decedent’s human remains and make arrangements for hydrolysis at:

Hydrolysis Licensee*

(hereinafter referred to “Hydrolysis Licensee”)

whose address is:

in accordance with and subject to: (a) the terms and conditions set forth in this Authorization; (b) any applicable state or local laws, rules, and regulations; and (c) the rules and regulations of said Funeral Provider and/or Hydrolysis Licensee.

Acknowledgement: By initialing below, I/We hereby acknowledge each item set forth in Sections A through C above.

Initials of Authorizing Agent(s)

FORM BFS-59A – Standard Alkaline Hydrolysis Authorization Form (Rev. 09/2023)

D. If Decedent’s hydrolysis does not involve a funeral establishment or individual licensed pursuant to G.S. 90-210.25(a2)(2):

I/We hereby authorize:*

(hereinafter referred to as “Hydrolysis Licensee”)

whose address is:

to take possession Decedent’s human remains and make arrangements for hydrolysis in accordance with and subject to: (a) the terms and conditions set forth in this Authorization; (b) any applicable state or local laws, rules, and regulations; and (c) the rules and regulations of said Hydrolysis Licensee. E. Unless specifically permitted by G.S. 90-210.129(h), hydrolysis will be performed individually.

E. Unless specifically permitted by G.S. 90-210.129(h), hydrolysis will be performed individually.

F. Personal or valuable items to be returned to Authorizing Agent(s):

Delivery Instructions:

G. Hydrolysis begins with the placement of the hydrolysis container into the hydrolysis chamber where it will be subjected to pressurized, heated water and chemical solutions. I/We hereby authorize Hydrolysis Licensee to hydrolyze Decedent’s human remains. At the conclusion of the hydrolysis process, the hydrolyzed remains are removed from the hydrolysis chamber and allowed to cool and dry before pulverization. The process results in considerably more remains being returned than cremation and may require a larger initial container or urn than would be necessary for cremation.

H. Hydrolyzed remains are processed or pulverized to permit their placement in an initial container or other suitable container. I/We hereby authorize Hydrolysis Licensee to process and/or pulverize Decedent’s hydrolyzed remains. Unless another container type is purchased for the hydrolyzed remains of Decedent, Hydrolysis Licensee will place the hydrolyzed remains in an initial container that may not be recommended for any type of shipment. In the event the capacity of the initial container or any other container is insufficient to accommodate all of the hydrolyzed remains of Decedent, a separate initial container will be used and returned to the person(s) designated in ParagraphL of this Authorization.

I. Unless specifically prohibited by the manufacturer thereof, human remains may be hydrolyzed without first removing a pacemaker, other material, or implanted device(s). Hydrolysis Licensee will not; however, hydrolyze any human remains which contain any type of hazardous implanted mechanical device. In the event the remains of Decedent do contain such a device, Authorizing Agent(s) hereby authorize and instruct Funeral Provider or when not applicable, Hydrolysis License, its agents and employees to remove any and all hazardous mechanical devices from Decedent prior to the hydrolysis process. Any such removal must be carried out accordance to the manufacturer’s guidelines and any applicable law or rule.

TO THE BEST OF THE KNOWLEDGE OF AUTHORIZING AGENT(S), THE REMAINS OF DECEDENT:*

DO NOT

CONTAIN A PACEMAKER THAT IS NOT APPROVED FOR HYDROLYSIS BY THE PACEMAKER’S MANUFACTURER.

AUTHORIZING AGENT(S) CERTIFY THAT TO THE BEST OF HIS/HER/THEIR KNOWLEDGE, THE REMAINS OF DECEDENT:*

DO NOT

CONTAIN ANY TYPE OF HAZARDOUS IMPLANTED MECHANICAL DEVICE.

J. Hydrolysis Licensee reserves the right to reject a hydrolysis container that is not biodegradable. Remains received in a non-biodegradable container may be removed prior to hydrolysis and placed in a suitable container; and Hydrolysis Licensee reserves the right to dispose of such non-biodegradable container at its sole discretion. Hydrolysis Licensee is authorized to remove and discard any items attached to the hydrolysis container which may cause damage to the hydrolysis chamber.

Acknowledgement: By initialing below, I/We hereby acknowledge each item set forth in Sections D through J above.

Initials of Authorizing Agent(s)

FORM BFS-59A – Standard Alkaline Hydrolysis Authorization Form (Rev. 09/2023)

K. If no final disposition is given, the hydrolyzed remains of Decedent will be held by Funeral Provider or if not applicable, Hydrolysis Licensee, for 30 days before they are disposed of, unless the hydrolyzed remains of Decedent are received from Funeral Provider or if not applicable, Hydrolysis Licensee, prior to that time, in person, by Authorizing Agent(s) or his/her/their designee.

L. I/We authorize Funeral Provider or if not applicable, Hydrolysis Licensee, to return the hydrolyzed remains of Decedent according to my/our directive(s) below. I/We understand that the services and obligations of Hydrolysis Licensee shall be fulfilled when the hydrolyzed remains of Decedent are returned to the possession and custody of Funeral Provider, if applicable. I/We hereby authorize Funeral Provider or if not applicable, Hydrolysis Licensee, to arrange for the disposition of the hydrolyzed remains of Decedent as follows (complete appropriatedisposition):

Deliver to a Cemetery

Deliver the hydrolyzed remains of Decedent to a Cemetery

Cemetery Name

cemetery, with which arrangements have already been made for the hydrolyzed remains of Decedent to be:

Decedent Name

Deliver to a Postal Service

Delivery of the hydrolyzed remains of Decedent to the US Postal Service forshipment via Registered, Return

Receipt mail to:

whose address is:

Release to Specified Persons

Release the hydrolyzed remains of Decedent to the following designated person(s):

Designated Person Name

First Last

Relationship

Designated Person Name

First Last

Relationship

Designated Person Name

First Last

Relationship

Designated Person Name

First Last

Relationship

Special instructions to be followed:

Other (Describe)

Other Instructions to be Followed:

M. Authorizing Agent(s) understand(s) that after this Standard Alkaline Hydrolysis Authorization Form is executed, Authorizing Agent(s) can only revoke the authorization and instruct Funeral Provider and/or Hydrolysis Licensee to cancel the hydrolysis and to release or deliver Decedent’s remains to another funeral provider and/or hydrolysis licensee by providing such instructions to Hydrolysis Licensee in writing prior to the commencement of hydrolysis. Hydrolysis Licensee shall honor these instructions provided that it receives such instructions prior to commencement of the hydrolysis of Decedent's human remains.

N. Pursuant to G.S. 90-210.125(c), a hydrolysis licensee shall have the legal right to hydrolyze human remains upon the receipt of a hydrolysis authorization form signed by an authorizing agent. There shall be no liability for a hydrolysis licensee that hydrolyzes human remains pursuant to such authorization, or that releases or disposes of the hydrolyzed remains pursuant to such authorization, except for such hydrolysis licensee’s gross negligence, provided that thehydrolysis licensee performs such functions in compliance with the provisions of NC General Statutes Chapter 90, Article 13F. There shall be no liability for a funeral establishment or individual licensed pursuant to G.S. 90-210.25(a2)(2) or licensee thereof that causes a hydrolysis licensee to hydrolyze human remains pursuant to such authorization, except for gross negligence, provided that the funeral establishment or individual licensed pursuant to G.S. 90-210.25(a2)(2) and licensee thereof and hydrolysis license perform their respective functions in compliance with the provisions of G.S. 90-210.125.

Acknowledgement: By initialing below, I/We hereby acknowledge each item set forth in Sections K through N above.

Initials of Authorizing Agent(s)*

FORM BFS-59A – Standard Alkaline Hydrolysis Authorization Form (Rev. 09/2023)

O. If this Standard Alkaline Hydrolysis Authorization Form is being executed on a preneed basis: 1. By placing his or her initials in the appropriate line, Authorizing Agent indicates his or her election of saidoption:

I do not wish to allow any of my survivors the option of canceling my hydrolysis and selecting alternative arrangements, regardless of whether my survivors deem such a change to be appropriate.*

I wish to allow only the survivors whom I have designated below the option of canceling my hydrolysis and selecting alternative arrangements or continuing to honor my wishes for hydrolysis and purchasing services and merchandise if they deem such a change to beappropriate.*

Name(s) of Survivors

2. Authorizing Agent may specify in writing religious practices that conflict with Article 13 of Chapter 90 of the North Carolina General Statutes. Funeral Provider and/or Hydrolysis Licensee shall observe these religious practices except where they interfere with: (i) hydrolyzation in a licensed hydrolysis provider as specified under G.S. 90-210.136 or (ii) the required documentation and recordkeeping.

Religious practices which conflict

(Religious practices which conflict with Article 13 of Chapter 90 of the North Carolina General Statutes)

SIGNATURE OF AUTHORIZING AGENT(S) FOR HYDROLYSIS AND FINAL DISPOSITION

By executing this Standard Alkaline Hydrolysis Authorization Form, as Authorizing Agent(s), the undersigned warrant that all representations and statements, except for Sections C or D and Sections I, if that information is unknown to Authorizing Agent(s), contained on this form are true and correct, that these statements were made to induce Hydrolysis Licensee to hydrolyze the human remains of the Decedent, and that the undersigned have read and understand the provisions contained on this form.

Authorizing Agent*

First Last

Signature*

Date of Signature

Time of Signature

Relationship to decedent

Phone

Address

Authorizing Agent

First Last

Signature

Date of Signature

Time of Signature

Relationship to decedent

Phone

Address

Authorizing Agent

First Last

Signature

Date of Signature

Time of Signature

Relationship to decedent

Phone

Address

Authorizing Agent

First Last

Signature

Date of Signature

Time of Signature

Relationship to decedent

Phone

Address

FORM BFS-59A – Standard Alkaline Hydrolysis Authorization Form (Rev. 09/2023)

NOTICE FOR PRENEED HYDROLYSIS ARRANGEMENTS:

Per G.S. 90-210.126, “[a]ny person, on a preneed basis, may authorize the person’s own cremation and the final disposition of the person’s cremated remains by executing, as authorizing agent, a cremation authorization form on a preneed basis and having the form signed by two witnesses.”. Per G.S. 90-210.136, “[t]he hydrolysis of human remains shall be conducted in compliance with all requirements for cremation[.]”.

WITNESSES

Two (2) witnesses are required if this Standard Alkaline Hydrolysis Authorization Form was executed on a preneed basis. Witnesses are not required by law if this Standard Alkaline Hydrolysis Authorization Form was executed on an at-need basis. However, some funeral providers and/or hydrolysis licensees may require two (2) witnesses if this Standard Alkaline Hydrolysis Authorization Form was not signed by the authorizing agent(s) in the presence of a funeral director/funeral service licensee or a hydrolysis licensee representative.

Witness*

First Last

Signature*

Date of Signature

Time of Signature

Address

Witness

First Last

Signature

Date of Signature

Time of Signature

Address

NOTARY

A notary is not required by law. However, some funeral providers and/orhydrolysis licensees may require a notary if this StandardAlkaline Hydrolysis Authorization Form is not signed by the authorizing agent(s) in the presence of a funeral director/funeral service licensee or a hydrolysis licensee representative.

STATE OF*

COUNTY OF*

I certify that*

personally appeared before me this day, acknowledging to me that he or she signed the foregoing Standard Alkaline Hydrolysis Authorization Form.

My commission expires:

FORM BFS-59A – Standard Alkaline Hydrolysis Authorization Form (Rev. 09/2023)

REPRESENTATIONS OF FUNERAL DIRECTOR / FUNERAL SERVICE LICENSEE

By executing this authorization form as a funeral director or funeral service licensee and an agent / employee of Funeral Provider, I warrant to the best of my knowledge that (1) Funeral Provider was responsible for making arrangements with Authorizing Agent(s) for the hydrolysis of Decedent and that I have reviewed this authorization form with Authorizing Agent (s); (2) that no employee of Funeral Provider has any knowledge or information that would lead it to believe that any of the answers provided on this form, by Authorizing Agent(s), are incorrect; (3) that the human remains delivered to Hydrolysis Licensee and represented as the human remains specified on this form are in fact the human remains that were identified to Funeral Provideras Decedent; and (4) that Funeral Provider obtained all necessary permits authorizing the hydrolysis of Decedent, including approval from the Office of the Chief Medical Examiner, if required. I understand that failureto complete this authorization in its entirety and other required documentation will result in the delay of the hydrolysis of Decedent.

Funeral Director or Funeral Service Licensee:

License Number

Signature

Date of Signature

REPRESENTATIONS OF HYDROLYSIS LICENSEE

Funeral Director or Funeral Service Licensee:

First Last

License Number

Signature

Date of Signature

REPRESENTATIONS OF HYDROLYSIS LICENSEE

(To be completed by hydrolysis licensee when no funeral provider involved)

By executing this authorization form as an agent / employee of Hydrolysis Licensee, I warrant to the best of my knowledge that (1) Hydrolysis Licensee was responsible for making arrangements with Authorizing Agent(s) for the hydrolysis of Decedent and that I have reviewed this authorization form with Authorizing Agent(s); (2) that no employee of Hydrolysis Licensee has any knowledge or information that would lead it to believe that any of the answers provided on this form, by Authorizing Agent(s), are incorrect; and (3) that Hydrolysis Licensee obtained all necessary permits authorizing them hydrolysis of Decedent, including approval from the Office of the Chief Medical Examiner, if required. I understand that failure to complete this authorization in its entirety and other required documentation will result in the delay of the hydrolysis of Decedent.

Representative of Hydrolysis Licensee:

Signature

Date

FOR HYDROLYSIS LICENSEE USE ONLY

Hydrolysis approved by:

Date

Special Instructions:

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“
December 8, 2023
I had no plans at all! From the first call to Dale Groce, letting him know of Jerry's passing, he was at Carepartners Solace in 20 mins. He was greeting everyone, and his compassionate nature was overflowing!! He said they would be there, no rush to plan, just to let him know when we were ready. That made the whole process for us to plan just open up. We met, planned as Dale's professionalism was evident from the start. He listened as we talked, taking notes, and asked us to tell him about Jerry. Dale Groce and his staff were Amazing!! They helped us turn a very sad situation into a wonderful celebration of Life. We are forever grateful for Groce Funeral Home. 10 isn't high enough!

Tanya Gosnell
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I honestly can't say thank you enough to the amazing staff at Groce Funeral Home. I truly feel they have treated my family and I like we were part of theirs. They provided unparalleled support during what is an incredibly challenging time for anyone. I want to mention Al in particular. From all aspects of this process, Al has been extremely understanding, helpful and a source of comfort.

Matthew S.
“
When my mother passed my sister had to work with two Funeral homes and many people to make sure my mother's final wishes were met. Out of all the people Groce Funeral home was the most professional. Dale Groce is in the business he was ment to do he is kind, understanding and very professional our family couldn't of asked for a better person to work with in such a sad time for my family. I would recommend Groce Funeral home. Thank you to you all at Groce's.

Moni
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Long standing friends. The very best of care always.

Peggy M.
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A class act as far as Im concerned no better place to help with your needs. I have just lost my Brother in-law and used a different funeral home.......will never make that mistake again. There are absolutely no worries when using Groce.

Gib K.Gib K.
“
Groce Funeral Home Inc is top notch. The morticians and staff at Groce are so very kind and caring to those who have just lost loved ones. They are very patient, and are not pushy when you are trying to make decisions about what to do during that delicate time. I would recommend to anyone.

Dana
“
The Groce Family has taking such amazing care of our family in times of grief. They are wonderful and caring people. I highly recommend them.

Eva Michelle Spieder
“
Groce funeral home handled everything very professionally when my Father passed away. Made it a lot easier for the family

Donna S.
“
A sincere thank you to the staff of Groce Funeral Home for your gentle kindness and care of my precious sister, Wanda King Stines. Groce has helped with our family over the years in making sure our loved ones are treated with respect. A very special thank you to Trey for all you help.

Linda L.
“
September 28, 2021
Thank you so much Scott for your kind and compassionate service. The staff has been super easy to work with during this challenging time. Y'all treated my father as if he were part of your family. That will never be forgotten.

Andy M.
“
October 6, 2016
We had the most incredible experience with Scott and the staff. Their job is far from easy but they manage to make you feel like you are so special. They take care of your loved one like they were part of their family. Extremely professional but they have such warmth. They go over and beyond to handle a heartbreaking situation with grace , dignity and comfort. Honestly 5 stars are not enough!!

Sherri M.
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Very caring and,people very respectful

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They do a great job. You can't really be happy about going here but they do their best to make things easier.

Jazzy Guide
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These are great people and very sympathetic towards your family during a loss of your loved one...... we have used Groce for everyone in our family. Thank you for all you do.

Lisa Quintero
“
Groce won me over when my friend had a stillborn and she was very young, unmarried and no money. They took care of the baby just the same. No one else (other funeral homes) would talk to her about helping. Since then all of my family goes there and that li'l babys' family as well.

Jan Nash
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Jonathan helped us get a glass heart made with my brother's ashes mixed in. On top of that he took time out of his busy day to get it to me. I know that delivery is not a normal service and I really appreciated it. Also the heart looks amazing.

Abundant Life
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My mom and I pre-planned arrangements for dad while he was in hospice. It was a comforting experience with no pressure. When dad passed it was nice to have arrangements in place and everything with regard to viewing and funeral service unfolded with dignity and ease. We appreciate the support of the staff and use of the beautiful facility.

Yin Yang
“
My former husband passed away suddenly last year and Trey was such a blessing to me as he simplified that part of an otherwise stressful circumstance. Now, my brother's care is entrusted to them and I have no doubt that he is being well-cared for

Joyce Landreth
“
My Father recently passed away. He had the forethought to pre-plan his own Funeral. He worked with Greg at the Lake Julian location. Greg and his team provided excellent guidance to help my Father put the plan in place. Last week, my Father finally passed on. Greg and the team at Groce helped us coordinate the entire proceedings from out-of-state. My Father was Veteran and I believe Greg's experience of being a vet himself, really helped to coordinate with officials to facilitate Dad's burial with Military Honors at the VA Cemetery in Black Mountain. My entire family was pleased with the Groce Team and we highly recommend their services for your loved one.

Bill Young