PACIFIC MEMORIAL SCATTERINGS AT SEA
AUTHORIZATION FORM 

Please print, complete and mail to:
P. O. Box 4073
Brookings, Or 97415 

Tel: (541) 251-4562 

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Date of authorization: ______________________________ 

I hereby authorize and request Pacific Memorial to take possession and 
arrange for the scattering of the cremated remains of___________________________ 
(Deceased as printed on death certificate) at sea, by vessel, in the Pacific Ocean, 
in accordance with and subject to the terms and conditions set forth in this 
Authorization 
and any applicable Federal, State or local laws and regulations.

I certify that I have legal right and authority to authorize this said disposition.

Authorizing Signature(s): ______________________________________

Print Name(s): _______________________________________

Relationship to Deceased: ____________________________

Address(s): ________________________________________________________________

Telephone Number(s): _______________________________

Special Instructions: ____________________________________________________________

Scattering to be attended by family: YES ____   NO ____

Scattering to be performed by family: YES ____   NO ____

Shipment of remains to Pacific Memorial by: 

U.S. Mail (Return Receipt Requested) ____

Or Other (Explain) __________________________________________ 


Once the cremains are scattered at sea, they are unrecoverable. Unless specified 
otherwise, once the cremains of the Deceased have been scattered, Pacific Memorial 
reserves the right to dispose of the container in which the cremated remains 
were held.

The responsibility of Pacific Memorial shall be limited to the disposition of the 
Deceased's cremated remains as directed herein. I agree to release and hold harmless 
Pacific Memorial from any and all loss, damage, or liability in connection with the 
disposition of the cremated remains of the Deceased as authorized herein.

Pacific Memorial is not responsible for any loss or damage of cremains while being 
shipped. 

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