Appointment of Agent to Control Disposition of Remains

I, ______________________________ being of sound mind, willfully and voluntarily make known my desire that, upon my death, the dis…. remains shall be controlled by _____________________ (name of agent first named) respect to that subject oly, I hereby appoint such person as my agent (attorney) decisions made by my agent with respect to the disposition of my remains including …… be binding.

SPECIAL DIRECTIONS:

            Set forth below are any special directions limiting the power granted to be my agent:

_______________________________

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If the disposition of my remains is by cremation, then:

(  ) I do not wish to allow any of my survivors the option of cancelling my cremations alternative arrangements, regardless of whether my survivors deem a change to be appropriate.

(  ) I wish to allow only the survivors I have designated below the option of cancelling my … selecting alternative arrangements, if they deem a change to be appropriate. ______________________________

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ASSUMPTION

            THE AGENT, AND EACH SUCCESSOR AGENT, BY ACCEPTING THIS APPOINTMENT, AGREES TO ASSUME THE OBLIGATIONS PROVIDED HEREIN.  AN AGENT…. TIME, BUT AN AGENT’S AUTHORITY TO ACT IS NOT EFFECTIVE UNTIL THE AGENT SIGNS BELOW ACCEPTANCE OF APPOINTMENT. ANY NUMBER OF AGENTS MAY SIGN, BUT ONLY THE SIGNATURE OF … AT ANY TIME IS REQUIRED.

AGENT:

Name: ________________________________________________

Address:_______________________________________________

Telephone Number: ______________________________

Signature Indicating Acceptance of Appointment_________________________

Date of Signature:________________________________

SUCCESSOR:

            If my agent dies, is determined by a court to be under a legal disability, resigns, or refuses to act, I hereby appoint the following to act alone and successively, in the order) to serve as my agent (attorney control the disposition of my remains as authorized by this document:

1. First Successor

Name: ______________________________________

Address:____________________________________

Telephone Number: _____________________________

Signature Indicating Acceptance of Appointment________________________

Date of Signature:_____________________________

2. Second Successor

Name: ___________________________________________

Address:__________________________________________

Telephone Number: ______________________________

Signature Indicating Acceptance of Appointment_________________________

Date of Signature:________________________________

DURATION

This appointment becomes effective upon my death.

PRIOR APPOINTMENTS REVOKED:

            I hereby revoke any prior appointment of any person to control the disposition of my remains.

RELIANCE

            I hereby agree that any hospital, cemetery organization, business operating a crematory or columbarium or both, funeral director or funeral establishment who receives a copy of this document may act under it.  Any revocation of this document I not effective  a to any such party until that party notice of the modification or revocation.  No such party shall be liable because of copy of this document.

Signed this ___________day of ___________________________, 20______

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State of _________________

County of _______________

            BEFORE ME, the undersigned, a Notary Public, on this day personally appeared ________________________, proved to me on the basis of satisfaction be the person whose name is subscribed to this foregoing instrument and acknowledge he/she executed the same for the purposes and consideration therein expressed.

GIVEN UNDER MY HAND AND SEAL OF OFFICE THIS ___________day of ____________, 20___

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Printed Name: _____________________

Notary  Public, State of ___________________

My commission expires:__________________________