Fill and Sign the Disposition Document Form

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, willfully 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 ASSUMESTHE 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 of First Successor Indicating Acceptance of Appointment: ______________________________ Date of Signature:____________ (2) Second Successor Name: __________________________ Address: __________________________ Telephone Number: __________________________ Signature of Second Successor 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 that a change to be appropriate: _______________________ Signature _______________________ Date State of Alaska ____________ Judicial District The foregoing instrument was acknowledged before me this ______ day of __________________ , 20 ______ by ______________________________ (signing party) __________________ (marital status). Given under my hand this the ______ day of __________________ , 20 ______ Notary Public My commission expires: