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 thisday of
Signature of declarant
I hereby accept appointment as representative for the control of final disposition of the declarant's remains.
Signed thisday of
Signature of representative
I hereby accept appointment as successor representative for the control of final disposition of the declarant's remains.
Signed thisday of
Signature of first successor representative
Signed thisday 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
154.30(9)
(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:
154.30(9)(a)
(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.
154.30(9)(b)
(b) Revoking in writing the authorization for final disposition. The declarant shall sign and date any written revocation under this subsection.
154.30(9)(c)
(c) Executing a subsequent authorization for final disposition.
154.30(10)
(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.
154.30 History
History: 2007 a. 58;
2009 a. 180,
197.
