Fill and Sign the Texas Agent Form

Appointment for Disposition of Remains I, _____________________________________________________ (your name and address) being of sound mind, willfully and vo luntarily make known my desire that, upon my death, the disposition of my rema ins shall be controlled by _____________________________ (name of agent) in accordance w ith Section 711.002 of the Health and Safety Code, and with respect to that subject only, I hereby appoint such person as my agent (attorney-in-fact). All decisions made by my agen t with respect to the disposition of my remains, including cremation, shall be binding. SPECIAL DIRECTIONS: Set forth below are any special directions limiting the power granted to my agent: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ AGENT: Name: ___________________________ Address: ___________________________ ___________________________ Telephone Number: ___________________________ SUCCESSORS: If my agent or a successor agent dies, become s legally disabled, resigns, or refuses to act, or if I divorce my agent or successor agent and this instrument does not state that the divorced agent or successor agent continues to serve after my divorce from that agent or successor agent, I hereby appoint the following persons (each to act alone and successively, in the order named) to serve as my agent (attorney-in-fact) to control the disposition of my remains as authorized by this document: 1. First Successor Name: ___________________________ Address: ___________________________ ___________________________ Telephone Number: ___________________________ Appointment for Disposition of Remains Page 2 2. Second Successor Name: ___________________________ Address: ___________________________ ___________________________ Telephone Number: ___________________________ 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 cemetery orga nization, business operating a crematory or columbarium or both, funeral director or embalm er, or funeral establishment who receives a copy of this document may act under it. Any modi fication or revocation of this document is not effective as to any such party until that party receives actual notice of the modification or revocation. No such party shall be liable b ecause of reliance on a copy of this document. ASSUMPTION: THE AGENT, AND EACH SUCCESSOR AGENT, BY ACCEPTING THIS APPOINTMENT, ASSUMES THE OBLIGATIONS PROVIDED IN , AND IS BOUND BY THE PROVISIONS OF, SECTION 711.002 OF THE HE ALTH AND SAFETY CODE. SIGNATURES: This written instrument and my appointments of an agent and any successor agent in this instrument are valid without the signature of my agent and my successor agents below. Each agent, or a successor agent, acting pursuant to this appointment must indicate acceptance of the appointment by signing below be fore acting as my agent. Signed this ________ day of _______________________________, 20___. ___________________________________________ (your signature) Appointment for Disposition of Remains Page 3 State of __________________ County of ________________ This document was acknowledged before me on _____________________ (date) by ____________________________ (name of principal). _________________________________________ (signature of notarial officer) (Seal, if any, of notary) __________________________________________ (printed name) My commission expires: ___________________________________ ACCEPTANCE AND ASSUMPTION BY AGENT: I have no knowledge of or any reason to beli eve this Appointment for Disposition of Remains has been revoked. I hereby accept the appointment made in this instrument with the understanding that I will be in dividually liable for the reasonable cost of the decedent's interment, for which I may seek reim bursement from the decedent's estate. Acceptance of Appointment: ___________________________________________ (signature of agent) Date of Signature: ____________________________ Acceptance of Appointment: ___________________________________________ (signature of first successor) Date of Signature: ____________________________ Acceptance of Appointment: ___________________________________________ (signature of second successor) Date of Signature: ____________________________