Assign An Agent to Control
Disposition of Remains Form

APPOINTMENT OF AGENT TO CONTROL DISPOSITION OF REMAINS

I, the designator, ___________________________________________voluntarily make known my desire that, upon my death, the control of the disposition of my dead body be controlled by __________________________________________________________________, and with respect to that subject only, I hereby appoint the above named person as my "agent to control the disposition of my remains." 

 

This designated agent has complete authority to act on my behalf and direct any and all details related to my after-death care, including: obituary, funeral or memorial service, cemetery, monument, memorialization, reception, final disposition, and other related matters.

 

SPECIAL DIRECTIONS: Set forth below are any special directions limiting the power granted to my agent as well as any instructions or wishes desired to be followed in the disposition of my remains: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

I have entered into a pre-paid pre-need contract with a mortuary or cemetery: yes / no

If yes, name of entity: __________________________________________________

I have provided a copy to my agent, attached. 

 

FUNDING: I have provided sufficient funds to pay for my after-death care in this way: _____________________________________________________________________  If for any reason those funds become inadequate, my designated agent is personally responsible to pay only the balance of those costs that he/she authorized. My agent has full authority to make any changes to reduce the cost of my after-deathcare.

 

DURATION: This appointment becomes effective upon my death.

 

PRIOR APPOINTMENTS REVOKED: I hereby revoke any prior appointment of any person to control the disposition of my remains, including (if a different person) a personal representative named in my will (according to Utah code 75-3-701).

 

RELIANCE: Any cemetery organization, business operating a crematory or columbarium or both, funeral director, embalmer, dispositioner, funeral committee or mortuary, Vital Records Registrar, or Care Facility who receives a copy of this document may act under it. No business or agency shall be liable because of reliance on a copy of this document.

 

ASSUMPTION: MY AGENT, BY ACCEPTING THIS APPOINTMENT, ASSUMES THE OBLIGATIONS PROVIDED HEREIN, AND IS BOUND BY THE PROVISIONS OF, UTAH SECTION 58-9-602 which states that a person designated in writing has the first right and duty to control the disposition and funeral arrangements of a deceased person.

 

Make this form official by signing in front of a notary, or follow Utah law for witness signatures. (Utah code 58-9-602(1)(a) and 75-2-502(1)(a)(b)(c)).

 

Designated Agent acceptance of appointment:

Signature

Print Name                                                                                               Date:

 

SUCCESSORS:

If my agent or a successor agent dies, becomes legally disabled, resigns, or refuses to act, or if my marriage to my agent or successor agent is dissolved by divorce, annulled, or declared void before my death (and this instrument does not state that the agent or

successor agent continues to serve in that circumstance), I hereby appoint the following persons (each to act alone and successively, in the order named) to serve as my agent to control the disposition of my remains as authorized by this document:

 

1st Successor Signature                                                                                        Date:

Print Name

 

 

2nd Successor Signature                                                                                       Date:

Print Name

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WITNESSES affirm DESIGNATOR made the stipulations stated above

 

Signature Witness 1:                                                                       Date:

Print Name

 

Signature Witness 2:                                                                       Date:

Print Name     

 

Or Notarized:

 

In the STATE OF UTAH, COUNTY OF  ______________________    

 

The foregoing instrument was acknowledged by the DESIGNATOR

______________________________________________________ (name) before me

 

this_____________________(date)

 

 (Seal)

 

 

 

Notary Public Printed Name:                                                             Commission Expires: