Appointment of Agent Form

An Agent is the individual who will be handling the funeral.

Appointment of Agent to control Disposition of Remains

This document shall constitute the "written instrument" asprovided in Section 42or of the NYS Public Health Law
I,
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
being of sound mind, willfully and voluntarily make known my desire that, upon my death, the disposition of my remains shall be controlled by:
Name of Agent*
First Last
With respect to that subject only, I hereby appoint such person as my age with respect to the disposition of my remains.
A. SPECIAL DIRECTIONS
Setforth below are any specialdirections limiting the power granted to my agent,as well as any instructions or wishes desired to be followed in the disposition of my remains:
Indicate below if you have entered into a pre-funded,pre-need agreement subject to Section 453 of the NYS General Business Law for funeral merchandise or services in advance of need:*
- NO, I have not entered into a pre-funded, pre-need agreement subject to Section 459 of the NYS General Business Law.
- YES, I have entered into a pre-funded, pre-need agreement subject to Section 453 of the NYS General Business Law.
Name of funeral firm with which you entered into a pre-funded pre-need funeral agreement to provide merchandise and/or services)
B. AGENT INFORMATION
Name of Agent*
First Last
Address of Agent*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Agent Telephone:*
Agent Additional Telephone:
C. SUCCESSORS
If my agent dies, resigns, or is unable or unwilling to act, 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:
First Successor*
First Last
Address of First Successor*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
First Successor Telephone:*
First Successor Additional Telephone:
Second Successor
First Last
Address of Second Successor
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Second Successor Telephone:
Second Successor Additional Telephone:
D. DURATION
This appointment becomes effective upon my death.
E. PRIOR APPOINTMENT REVOKED
I hereby revoke any prior appointment of any person to control the disposition of my remains.
Agreement Date*
Date Format: MM slash DD slash YYYY
Signature
I hereby revoke any prior appointment of any person to control the disposition of my remains

516-481-7460
718-388-4416

Flowers

Appointment of Agent to control Disposition of Remains

A. SPECIAL DIRECTIONS

B. AGENT INFORMATION

C. SUCCESSORS

D. DURATION

E. PRIOR APPOINTMENT REVOKED