****(Must be completed in its entirety)****

Name of Pet Owner:

Address of Pet Owner:

Phone #:

Date of Death:

Name of Pet:

Type of Pet:

Approximate Weight:

Name and address of Crematory:
La Paloma Pet Cremation
5450 Stephanie Street, Suite #115
Las Vegas, NV 89122
ph. (702) 739-4838
fax (702) 435-0099

1. Cremation Authorization: The owner hereby authorizes La Paloma Pet Cremation to cremate the remains of the pet listed above. In providing this authorization, the undersigned represents that he or she is the Owner or Legal Representative of the Owner and has the full right and authority to arrange the cremation and the disposition of the cremated remains of the above-named Pet.

2. Cremation Process: The undersigned acknowledges that due to the nature of the cremation process, any material on the remains of the Pet, such as collars, tags, etc., will be destroyed if not removed. Accordingly, the undersigned has removed any such material or, if the material is present on the Pet's remains, the undersigned understands it will either be destroyed or removed and disposed of by La Paloma Pet Cremation.

3. Disposition of Cremated Remains: The undersigned directs La Paloma Pet Cremation to take the following actions with regard to the cremated remains of the above-listed Pet.

Hold the cremated remains until picked up by the Owner. If not picked up within fourteen (14) days of the date of death, La Paloma Pet Cremation may dispose of the cremated remains in any lawful manner or if storage is requested, a storage fee of $10 per month will apply after the initial fourteen (14) days.

Deliver the cremated remains to the following address: (enter your address in the space provided)
Please note:
There will be a $20 delivery charge plus $1.00 per additional mile outside of 25 miles of our facility.

Return Cremated Remains to veterinarian.
Name of Veterinarian:

Address of Veterinarian:

Other

4. Certification: The undersigned certifies the accuracy of all the information on this Authorization and will indemnify and hold harmless La Paloma Pet Cremation, their owners, employees and agents, from any liability, cost, expenses or claims resulting from the Authorization and release thereon.

5. Pacemakers and Defibrillators:
The undersigned certifies that the above-named pet
and will compensate La Paloma Pet Cremation if damage occurs due to the fact that la Paloma was not advised of a pacemaker or defibrilator.

BY SUBMITTING THIS FORM YOU UNDERSTAND THAT THE CHARGE FOR ALL THE ABOVE SHALL BE PAID IN FULL PRIOR TO COMPLETION OF SERVICES.

YOUR Full Name (Electronic Signature):

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