I certify that this pet has been in my custody and under my supervision and that to the best of my knowledge has not bitten any person or animal with in the past 10 days.

I certify that I am the owner or authorized agent of the owner of the pet described below.

I authorize the veterinarian or staff member under my supervision of veterinarian at Roseville Animal Hospital, to take possession of my pet for cremation purposes that l, as the pet owner have specified.