6. A health care provider.
8. A social worker.
(f) The department shall prepare and provide copies of the authorization for final disposition form and accompanying information for distribution in quantities to funeral directors, crematory authorities, cemetery authorities, hospitals, nursing homes, county clerks, and local bar associations and individually to private persons. The department shall include, in information accompanying the authorization for final disposition form, at least the statutory definitions of terms used in the form, and an instruction to potential declarants to read and understand the information before completing the form. The department may charge a reasonable fee for the cost of preparation and distribution. The authorization for final disposition form distributed by the department shall be easy to read, in not less than 10-point type, and in the following 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 revocation. 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........................................
(9) Revocation of authorization for final disposition. A declarant may revoke an authorization for final disposition at any time by any of the following methods:
(a) Cancelling, defacing, obliterating, burning, tearing, or otherwise destroying the authorization for final disposition or directing some other person to cancel, deface, obliterate, burn, tear, or otherwise destroy the authorization for final disposition in the presence of the declarant. In this paragraph, "cancelling" includes a declarant's writing on a declaration of final disposition, "I hereby revoke this declaration of final disposition," and signing and dating that statement.
(b) Revoking in writing the authorization for final disposition. The declarant shall sign and date any written revocation under this subsection.
(c) Executing a subsequent authorization for final disposition.
(10) Penalty. Any person who intentionally conceals, cancels, defaces, obliterates, or damages the authorization for final disposition of another without the declarant's consent may be fined not more than $500 or imprisoned not more than 30 days or both.
