APPOINTMENT OF AGENT TO CONTROL DISPOSITION OF REMAINS

I, _______________________________________________________________ (your name and address), being of sound mind, willfully and voluntarily make known my desire that, upon my death, the disposition of my remains shall be controlled by ____________________________ (name of agent) in accordance with 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 agent 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:

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AGENT:

Name: __________________________________________________________________

Address: ________________________________________________________________

Telephone Number: ________________________________________________________

Acceptance of Appointment: __________________________________ (signature of agent)

Date of Signature: __________________________________________________________

SUCCESSORS:

If my agent dies, becomes legally disabled, resigns, or refuses to act, 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: ________________________________________________________

Acceptance of Appointment: __________________________________ (signature of first successor)

Date of Signature: __________________________________________________________

2. Second Successor

Name: __________________________________________________________________

Address: ________________________________________________________________

Telephone Number: ________________________________________________________

Acceptance of Appointment: ________________________________(signature of second successor)

Date of Signature: __________________________________________________________

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 organization, business operating a crematory or columbarium or both, funeral director or embalmer, or funeral establishment who receives a copy of this document may act under it. Any modification 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 because 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 HEALTH AND SAFETY CODE.

Signed this _________________ day of __________________________, 19___.

_________________________________________________________ (your signature)

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: ______________________________________