Authority to Provide Services

This is an Authority for Internment or Cremation and Agreement as to Payment with Osbornes Funeral Directors Ltd.

Authority to Provide Services Form

First Authorised Person

Name(Required)

First Name(s) Last Name

Phone (Home)

Phone (Work)

Occupation

Employer

Relationship to the Deceased

Date of Birth(Required)

Email(Required)

Drivers License or Passport Number(Required)

Second Authorised Person

Name

First Name(s) Last Name

Phone (Home)

Phone (Work)

Occupation

Employer

Relationship to the Deceased

Date of Birth

Drivers License or Passport Number

Authorisation

Details of where to send the funeral account:

Name

First Name(s) Last Name

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Relationship to the deceased:

Do hereby authorise Osbornes Funeral Directors Ltd, 197 Old Taupo Road, Rotorua to Cremate/Inter/Care for:

Name of the Deceased:

Place of Death

Date of Death

Please tick as appropriate, then sign below:

I/We confirm that I/we am/are the person(s) authorised to enter into this agreement on behalf of the above named deceased.

I confirm that I have read and understood the above.

I confirm that I am responsible for all costs associated with the deceased account to be paid before the due date. Regardless of WINZ Funeral Grant, ACC Funeral Grant or Insurances.

I confirm that the estimate of costs has been discussed, and I will be sent a written estimate within 24 hours of our arrangements.

SIGNED by Executor / Administrator / Family Representative on behalf of the Estate of the Deceased and in my/our personal capacity:

Signatory Name(Required)

Signatory Name

Witnessed By:(Required)

Consent(Required)

I/WE CONFIRM that:
1. I/We are the person(s) named as Executor(s) in the will; or
2. I/We have been authorised to enter into this Agreement by the Executor(s) in the will; or
3. I/We have knowledge that the deceased died without leaving a will; or
4. I/We do not have knowledge as to whether the deceased died without leaving a will; and
5. I/We have obtained independent legal advice in relation to my/our authority and role on behalf of the .deceased.
I/WE ACKNOWLEDGE AND AGREE that as the party(s) entering into this agreement I/we accept responsibility for the payment of any and all debts, disbursements, fees and interest charges that have not been paid by or on behalf of the Estate of the Deceased at the expiration of four weeks from the date of death of the Deceased and that I/we will personally pay the same together with further interest at a rate set out below up to the date of payment including collection costs.
I/WE UNDERTAKE THAT I/we are duly authorised to give this authority and indemnify you and your officers, employees and agents against any and all demands, claims, liabilities, losses, costs, expenses and/or proceedings arising from any services and/or attendance herein authorised by me/we as are reasonably required.
I/WE FURTHER UNDERTAKE THAT I/we expressly waive any right to make any demand or claim against you arising out of any ADDITIONAL INSTRUCTIONS OR REQUESTS that I/we provide in relation to the funeral of the Deceased, including, but not limited to, the processing, embalming and preparation of the deceased, transportation of the deceased, the cremation, and the placement of any items or valuables in the casket of the deceased.
I/WE UNDERSTAND that this document does not contain a description of every aspect of the cremation/burial process and disposition.
I/WE AUTHORISE YOU to meet on my/our behalf all necessary debts and disbursements in respect of the funeral of the Deceased and to recover from me/us such outgoing together with your account for professional services AND IT IS AGREED that if I/we or the estate of the Deceased do not meet such debts, disbursements and fees within four weeks from the date of the death of the Deceased that the total account together with the appropriate Account Finance Charge shall incur interest at the rate of EIGHTEEN PERCENT (18%) per annum calculated at One and One Half Percent (1.5%) Per Month or part thereof on any outstanding balance inclusive of collection fees and interest until the date of payment to you.
I /WE AUTHORISE any person or company to provide you with such information as you may require in response to your credit and/or employment inquiries. I/we authorise you to furnish to such third party/s any details that I/we may have with you as a result of this application being actioned by you.

I agree to the statement above, and I confirm that the information provided is true and correct to the best of my knowledge.

Signed Date(Required)

Authority to Provide Services