Unattended scattering at sea Authorization form

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I hereby authorize Captain Dave's SF Bay Charters LLC (DBA: San Francisco Bay Boat Memorials, Captain Dave Gallegioni, CRD Lic. #901 or his designee) 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 (per California Code H&S 7100), 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 Captain Dave's SF Bay Charters LLC (Captain Dave Gallegioni) to make disposition of cremated remains of the Deceased at sea in: _ __ Pacific Ocean or ___San Francisco Bay (please check one) and provide email for pic to be sent.

I hereby direct Captain Dave's SF Bay Charters LLC (Captain Dave Gallegioni) to scatter said cremated remains at sea, in accordance with California State and Federal Law.

Special Instructions :
 

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If no specific instructions are provided herein, scattering will be performed by Captain Dave's SF Bay Charters LLC in a timely manner, weather and circumstances permitting.

"Scattering" consists of the scattering of cremated remains at sea including the San Francisco Bay generally in the vicinity of the Golden Gate Bridge. 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, Captain Dave's SF Bay Charters LLC (DBA San Francisco Bay Boat Memorials), Captain Dave Gallegioni will dispose of the container which contained said cremated remains.

The obligation of Captain Dave's SF Bay Charters LLC shall be limited to the disposition of the cremated remains as directed herein. I agree to release and hold harmless Captain Dave's SF Bay Charters LLC (DBA: San Francisco Bay Boat Memorials) Captain Dave Gallegioni, its' designee, 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.

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Signature

__ ______________________________ 

Print Name

___ ____________________________
 Relationship to Deceased

 ___________________________,
Address

 ____________________, ____ ____________
City     State     Zip Code

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Date