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.
