Fill and Sign the Ohio Burial Form

OHIO APPOINTMENT OF REPRESENTATIVE FOR DISPOSITION OF BODILY REMAINS, FUNERAL ARRANGEMENTS, AND BURIAL OR CREMATION GOODS AND SERVICES I, (legal name and address) ______________________________ , an adult being of sound mind, willfully and voluntarily appoint my representative, named below, to have the right of disposition, as defined in section 2108.70 of the Revised Code, for my body upon my death. All decisions made by my representative with respect to the right of disposition shall be binding. REPRESENTATIVE(S): (If the representative is a group of persons, indicate the name, last known address and phone number of each person in the group. Attach additional sheet if necessary.) Name: ______________________________ Address: ______________________________ Telephone Number: ______________________________ SUCCESSOR REPRESENTATIVE(S): If my representative is disqualified from serving as my representative as described in section 2108.75 of the Revised Code, then I hereby appoint the following person or group of persons to serve as my successor representative. (If the representative is a group of persons, indicate the name, last known address and phone number of each person in the group. Attach additional sheet if necessary.) Name: ______________________________ Address: ______________________________ Telephone Number: ______________________________ PREFERENCES REGARDING HOW THE RIGHT OF DISPOSITION SHOULD BE EXERCISED, INCLUDING ANY RELIGIOUS OBSERVANCES THE DECLARANT WISHES A REPRESENTATIVE OR A SUCCESSOR REPRESENTATIVE TO CONSIDER (attach additional sheets if necessary): ______________________________ _____________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 1 ______ ONE OR MORE SOURCES OF FUNDS THAT COULD BE USED TO PAY FOR GOODS AND SERVICES ASSOCIATED WITH AN EXERCISE OF THE RIGHT OF DISPOSITION : ______________________________ _______________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ DURATION : The appointment of my representative and, if applicable, successor representative, becomes effective upon my death. PRIOR APPOINTMENTS REVOKED : I hereby revoke any written declaration that I executed in accordance with section 2108.70 of the Ohio Revised Code prior to the date of execution of this written declaration indicated below. AUTHORIZATION TO ACT: I hereby agree that any of the following that receives a copy of this written declaration may act under it: - Cemetery organization; - Crematory operator; - Business operating a columbarium; - Funeral director; - Embalmer; - Funeral home; - Any other person (such as the representative named herein) asked to assist with my funeral, burial, cremation, or other manner of final disposition. MODIFICATION AND REVOCATION - WHEN EFFECTIVE : Any modification or revocation of this written declaration is not effective as to any party until that party receives actual notice of the modification or revocation. LIABILITY : No person who acts in accordance with a properly executed copy of this written declaration shall be liable for damages of any kind associated with the person's reliance on this declaration. Signed this _________ day of ______________________________ , 20 _________ . ________________________________________________________________________ (Signature of declarant) 2 ______ WITNESSES : I attest that the declarant signed or acknowledged this assignment of the right of disposition under section 2108.70 of the Revised Code in my presence and that the declarant is at least eighteen years of age and appears to be of sound mind and not under or subject to duress, fraud, or undue influence. I further attest that I am not the declarant's representative or successor representative, I am at least eighteen years of age, and I am not related to the declarant by blood, marriage, or adoption. First witness : Name (printed) ______________________________ Residing at: ______________________________ Signature:______________________________________ Date: ________________________ Second witness : Name (printed) ______________________________ Residing at: ______________________________ Signature:______________________________________ Date: ________________________ ~OR~ NOTARY ACKNOWLEDGMENT : State of Ohio, County of ______________________________ SS. On _____________________________________________ before me, the undersigned notary public, personally appeared ______________________________ known to me or satisfactorily proven to be the person whose name is subscribed as the declarant, and who has acknowledged that he or she executed this written declaration under section 2108.70 of the Revised Code for the purposes expressed in that section. I attest that the declarant is at least eighteen years of age and appears to be of sound mind and not under or subject to duress, fraud, or undue influence. Signature of notary public: _________________________________________________________ My commission expires on : _________________________________ 3 ______