A person who wishes to authorize another person to control the disposition of remains and the arrangements for funeral goods and services may execute a written instrument before a notary public. The written instrument shall be in substantially the following form:

“State of___________________

County of___________________

I, _______________ do hereby designate ________________ as the sole person who will have the right to determine and decide the disposition of my remains upon my death and the arrangements for funeral goods and services. I __ have/ __ have not attached specific directions concerning the disposition of my remains. If I have attached specific directions, the designee shall substantially comply with the specific directions, provided the directions are lawful and there are sufficient resources in my estate to carry out the directions.

SIGNATURE: Sign and date the form here:

____________________________ ___________________________

(sign your name) (date)

____________________________

(print your name)

DECLARATION OF NOTARY:

Subscribed and sworn before me, __________________ (insert name of notary public), on this _____________ day of _______________, in the year _______.

Notary Seal

____________________________

(Signature of Notary Public)”