Agreement to Receive Cremains

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Name of Deceased: *

Year of Birth:

Year of Death:

The claimant, agrees to reimburse Doña Ana County in exchange for the cremains of the above named deceased. The amount of $600.00 made payable to Doña Ana County. The amount will be paid prior to the release of cremains. ONLY a Money Order or Cashiers Check payment made to Doña Ana County will be accepted to: 845 N. Motel Blvd., Las Cruces NM 88007: ATTN: Health & Human Services, Program Operations Division Manager. (Cash, personal check or credit card payments cannot be accepted for payment).

Contact Information of Claimant:

Full Name (Print): *

Phone: *

Relationship to Deceased: *