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.
