This form gives permission to transfer the deceased from the place of death to our facility.

Release and Financial Responsibility

This form gives permission to transfer the deceased from the place of death to our facility.

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Name of Deceased*
First Middle Last
Place of Death: Residential Address or Name of Facility*
Name of Person Authorized to Release*
Relationship to Deceased*
Address of Person Authorize to Release*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Telephone Number of Person Authorized to Release*
Electronic Signature:
In accordance with RSA 294-D New Hampshire Digital Signature Act, I, the undersigned, hereby authorize and give permission to Phaneuf Funeral Homes and Crematorium, or their designated agent, to transfer the deceased from the place of death to their facility. I further authorize that I have the legal authority to make this decision and accept full financial responsibility for paying for the burial or cremation arrangements.

In the event I select another funeral home to handle final arrangements, I acknowledge I am responsible for any fees associated with transportation, sheltering, and refrigeration of the body.

By signing this form, I hereby acknowledge that a General Price List (GPL) has been made available to me either online at www.phaneuf.net or in person.
Full legal name of member or individual authorized to make arrangements:*
Electronic signature confirmation:*