Name of Deceased:

First Name
Middle
Last Name
Date of Death
Next of Kin
Relationship
Address
City
State/Province
Zip/Postal code
Home Phone
Work Phone
Fax Number
Email Address
Comments or Special Instructions
The undersigned who represents the above named deceased hereby states the he/she has the legal authority to do so.  The undersign does hereby authorize and direct Rollins Funeral Home or its agent to embalm the above named deceased individual in accordance with customary funeral practice laws governing the State of Mississippi. I hereby accept the terms of this agreement. I do not accept the terms of this agreement Please type in your Full Name