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DISPOSITION
DOCUMENT
You can select Part 1, Part 2, or both, by completing the part(s) you select, including providing any signatures indicated. Part 3 contains general statements and a place for your signature. You must sign in front of a notary.
PART 1. APPOINTMENT OF AGENT TO CONTROL DISPOSITION OF REMAINS.
If you appoint an agent, you and your agent must complete this part as indicated, and the agent must sign this part
I, __________________________________, being of sound mind, wilfully and voluntarily make known my desire
that, on my death, the disposition of my remains shall be controlled by __________________________________
(name of agent first named below), and, with respect to that subject only, I appoint that person as my agent.
All decisions made by my agent with respect to the disposition of my remains, including cremation, are binding
ACCEPTANCE BY AGENT OF APPOINTMENT
THE AGENT, AND EACH SUCCESSOR AGENT, BY ACCEPTING THIS APPOINTMENT, AGREES TO AND ASSUMES THE OBLIGATIONS PROVIDED
IN THIS DOCUMENT. AN AGENT MAY SIGN AT ANY TIME, BUT AN AGENT'S AUTHORITY TO ACT IS NOT EFFECTIVE UNTIL THE AGENT
SIGNS BELOW TO INDICATE THE ACCEPTANCE OF APPOINTMENT. ANY NUMBER OF AGENTS MAY SIGN, BUT ONLY THE SIGNATURE OF THE
AGENT ACTING AT ANY TIME IS REQUIRED
AGENT:
Name: ____________________________________________________________________________________________
Address: _________________________________________________________________________________________
Telephone Number: ________________________________________________________________________________
Signature Indicating Acceptance of Appointment:___________________________________________________
Date of Signature: _______________________________________________________________________________
SUCCESSORS:
If my agent dies, becomes legally disabled, resigns, or refuses to act, I appoint the following persons
(each to act alone and successively, in the order named) to serve as my agent to 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: _______________________________________________________________________________
PART 2. DIRECTIONS FOR THE DISPOSITION OF MY REMAINS
Stated below are my directions for the disposition of my remains:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
If the disposition of my remains is by cremation, then (pick one):
( ) I do not wish to allow any of my survivors the option of canceling my cremation and selecting alternative arrangements, regardless of whether my survivors consider a change to be appropriate.
( ) I wish to allow only the survivors I have designated below to have the option of canceling my cremation and selecting alternative arrangements, if they consider a change to be appropriate:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
PART 3. GENERAL PROVISIONS AND SIGNATURE
WHEN DIRECTIONS BECOME EFFECTIVE
The directions, including any appointment of an agent, in this disposition document become effective on my death.
REVOCATION OF PRIOR APPOINTMENTS
I revoke any prior appointment of any person to control the disposition of my remains.
SIGNATURE OF PERSON MAKING DISPOSITION DOCUMENT
Signature:________________________________________________________________________________________
Date of Signature: _______________________________________________________________________________
(Notary acknowledgment of signature)
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Note to HTML Version:
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