Fill and Sign the Final Disposition Authorization and Instructions Form

AUTHORIZATION FOR FINAL DISPOSITION I, ______________________________ (print name and address), being of sound mind, willfully and voluntarily make known by this document my desire that, upon my death, the final disposition of my remains be under the control of my representative under the requirements of section 154.30, Wisconsin statutes, and, with respect to that final disposition only, I hereby appoint the representative and any successor representative named in this document. All decisions made by my representative or any successor representative with respect to the final disposition of my remains are binding. Name of representative ______________________________ Address ______________________________ Telephone number ______________________________ If my representative dies, becomes incapacitated, resigns, refuses to act, ceases to be qualified, or cannot be located within the time necessary to control the final disposition of my remains, I hereby appoint the following individuals, each to act alone and successively, in the order specified, to serve as my successor representative: 1. Name of first successor representative ______________________________ Address ______________________________ Telephone number ______________________________ 2. Name of second successor representative ______________________________ Address ______________________________ Telephone number ______________________________ Suggested special directions ______________________________ Suggested instructions concerning religious observances ______________________________ Suggested source of funds for implementing final disposition directions and instructions ______________________________ This authorization becomes effective upon my death. I hereby revoke any prior authorization for final disposition that I may have signed before the date that this document is signed. I hereby agree that any funeral director, crematory authority, or cemetery authority that receives a copy of this document may act under it. Any modification or revocation of this document is not effective as to a funeral director, crematory authority, or cemetery authority until the funeral director, crematory authority, or cemetery authority receives actual notice of the modification or revoca tion. No funeral director, crematory authority, or cemetery authority may be liable because of reliance on a copy of this document. The representative and any successor representative, by accepting appointment under this document, assume the powers and duties specified for a representative under section 154.30, Wisconsin statutes. Signed this__________ day of ______________________________ Signature of declarant__________________________________________ I hereby accept appointment as representative for the control of final disposition of the declarant's remains. Signed this__________ day of ______________________________ Signature of representative_________________________________ I hereby accept appointment as successor representative for the control of final disposition of the declarant's remains. Signed this__________ day of ______________________________ Signature of first successor representative___________________________ Signed this__________ day of ______________________________ Signature of second successor representative_______________________________________________________ I attest that the declarant signed or acknowledged this authorization for final disposition in my presence and that the declarant appears to be of sound mind and not subject to duress, fraud, or undue influence. I further attest that I am not the representative or the successor representative appointed under this document, that I am aged at least 18, and that I am not related to the declarant by blood, marriage, or adoption. Witness (print name) ______________________________ Signature________________________________________________________ Address ______________________________ Date ______________________________ Witness (print name) ______________________________ Signature________________________________________________________ Address ______________________________ Date ______________________________ State of Wisconsin County of ______________________________ On ______________________________ (date), before me personally appeared ______________________________ (name of declarant) , known to me or satisfactorily proven to be the individual whose name is specified in this document as the declarant and who has acknowledged that he or she executed the document for the purposes expressed in it. I attest that the declarant appears to be of sound mind and not subject to duress, fraud, or undue influence. Notary public____________________________________________________ My commission expires____________________________________________