AB305,14,2222 Signed this .............................day of .................................
AB305,14,2323 Signature of representative...................................................................................
AB305,14,2524 I hereby accept appointment as successor representative for the control of final
25disposition of the declarant's remains.
AB305,15,1
1Signed this .............................day of .................................
AB305,15,22 Signature of first successor representative...........................................................
AB305,15,33 Signed this .............................day of .................................
AB305,15,44 Signature of second successor representative.......................................................
AB305,15,116 I attest that the declarant signed or acknowledged this authorization for final
7disposition in my presence and that the declarant appears to be of sound mind and
8not subject to duress, fraud, or undue influence. I further attest that I am not the
9representative or the successor representative appointed under this document, that
10I am aged at least 18, and that I am not related to the declarant by blood, marriage,
11or adoption.
AB305,15,1212 Witness (print name).............................................................................................
AB305,15,1313 Signature..........................................................................................................
AB305,15,1414 Address.............................................................................................................
AB305,15,1515 Date..................................................................................................................
AB305,15,1717 Witness (print name).............................................................................................
AB305,15,1818 Signature..........................................................................................................
AB305,15,1919 Address.............................................................................................................
AB305,15,2020 Date..................................................................................................................
AB305,15,2222 State of Wisconsin
AB305,15,2323 County of .................................
AB305,16,424 On (date)............................................................., before me personally appeared
25(name of declarant).................................................................., known to me or

1satisfactorily proven to be the individual whose name is specified in this document
2as the declarant and who has acknowledged that he or she executed the document
3for the purposes expressed in it. I attest that the declarant appears to be of sound
4mind and not subject to duress, fraud, or undue influence.
AB305,16,55 Notary public.........................................................................................................
AB305,16,66 My commission expires..........................................................................................
AB305,16,9 7(9) Revocation of authorization for final disposition. A declarant may
8revoke an authorization for final disposition at any time by any of the following
9methods:
AB305,16,1510 (a) Cancelling, defacing, obliterating, burning, tearing, or otherwise destroying
11the authorization for final disposition or directing some other person to cancel,
12deface, obliterate, burn, tear, or otherwise destroy the authorization for final
13disposition in the presence of the declarant. In this paragraph, "cancelling" includes
14a declarant's writing on a declaration of final disposition, "I hereby revoke this
15declaration of final disposition," and signing and dating that statement.
AB305,16,1716 (b) Revoking in writing the authorization for final disposition. The declarant
17shall sign and date any written revocation under this subsection.
AB305,16,1818 (c) Executing a subsequent authorization for final disposition.
AB305,16,22 19(10) Penalty. Any person who intentionally conceals, cancels, defaces,
20obliterates, or damages the authorization for final disposition of another without the
21declarant's consent may be fined not more than $500 or imprisoned not more than
2230 days or both.
AB305,16,2323 (End)
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