I hereby authorize PACIFIC COAST ASHES AT SEA to take possession of and make arrangements for, the disposition of the cremated remains of ______________________________________________ ("Deceased") in accordance with and subject to the terms and conditions set forth in this Authorization; the Company's Rules and Regulations; and any applicable federal, state, provincial or local laws and regulations.

I certify that I have the full legal right and authority to authorize the disposition of the remains of the Deceased.

I hereby authorize PACIFIC COAST ASHES AT SEA to make disposition of cremated remains of the Deceased at sea in:

I hereby direct PACIFIC COAST ASHES AT SEA to scatter said cremated remains at sea, in accordance with State and Federal Law.

Special Instructions:
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If no specific instructions are provided herein, scattering will be performed by PACIFIC COAST ASHES AT SEA, in a timely manner, weather permitting.

"Scattering" consists of the scattering of cremated remains at sea. I understand that once the cremated remains of the Deceased are scattered, they are unrecoverable. Unless otherwise specifically provided for herein, once scattering of cremated remains of the Deceased has been performed, PACIFIC COAST ASHES AT SEA will dispose of the container which contained said cremated remains.

The obligation of COAST TO COAST BURIAL AT SEA shall be limited to the disposition of the cremated remains as directed herein. I agree to release and hold harmless PACIFIC COAST ASHES AT SEA, its affiliates and their agents, employees, successors and assigns from any and all loss, damage, liability or causes of action (including attorney's fee and expenses of litigation) in connection with the disposition of the cremated remains of the Deceased as authorized herein or respect to the identification of said cremated remains as being those of the Deceased.

Date of authorization _______________________________