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Name

First Name Last Name

Address Street Address Street Address Line 2City State / Province Postal / Zip Code

Primary phone Patient's name breed sex color/markings age

burial service option (please select only one option). you may call our office for prices of cremation services).Home burial with casketCommunal cremation without ashes returnedPrivate cremation with ashes returned

Commemorative clay paw prints will be provided for all communal and private cremation services. Additional paw prints can be made for an additional fee. Would you like additional paw print made?YesNo

If you elected additional paw prints, enter how many you would like. Ashes and/or paw prints must be picked up within 90 days of today's date or we will dispose of the items as we see fit. Initial here to acknowledge

I, the undersigned, do hereby certify that i am the owner (duly authorized agent for the owner) of the animal described above, and i do hereby give the doctors of Fm 1488 Animal Medical center permission to euthanize said animal. i do also certify that to the best of my knowledge the said animal has not bitten any person during the last ten (10) days andhas not been exposed to rabies. Type your full name

Euthanasia Authorization