§ 5-33.3-4. Form of designation.
(a) The designation provided for in section 5-33.3-3 may be in substantially the following form:
I, (PRINCIPAL), do hereby name and designate (PRIMARY AGENT) as my primary funeral
planning agent, or if he/she is unwilling or incapable (ALTERNATE AGENT) as my alternate
funeral planning agent, who shall have the sole responsibility and authority to make
any and all arrangements and decisions regarding my funeral preparation and planning,
burial or disposition of my remains, including cremation, upon my death, pursuant
to the provisions of §â€‚5-33.2-24. By signing this document, the
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§ 5-33.3-4. Form of designation.
(a) The designation provided for in section 5-33.3-3 may be in substantially the following form:
I, (PRINCIPAL), do hereby name and designate (PRIMARY AGENT) as my primary funeral
planning agent, or if he/she is unwilling or incapable (ALTERNATE AGENT) as my alternate
funeral planning agent, who shall have the sole responsibility and authority to make
any and all arrangements and decisions regarding my funeral preparation and planning,
burial or disposition of my remains, including cremation, upon my death, pursuant
to the provisions of §â€‚5-33.2-24. By signing this document, the aforementioned agent(s) agree to ensure payment for
all outstanding expenses related to my funeral. The agent further certifies that if
I am a non-relative to the agent, then I am the only non-relative for whom the agent
is serving as a funeral planning agent. This document shall revoke and shall make
null and void any and all previous designations of a funeral planning agent.
| Witness: _________________________________________   |
Principal: _________________________________________ |
| _________________________________________ |
| (Name and address of Witness) |
Name and address of Principal: |
| _________________________________________   |
_________________________________________ |
| Dated: _______________________________________ |
Dated: _________________________________________ |
| Primary Agent: _______________________________________ |
Alternate Agent: _________________________________________ |
| Name and Address of Primary |
Name and Address of Alternate |
| Agent |
Agent |
| _________________________________________ |
| Dated: _______________________________________ |
Dated: _________________________________________ |
| State of _______________________________________ |
County of _________________________________________ |
| Subscribed and sworn to before me this _____________________ day of _________________________________________ |
| _________________________________________ |
| _______________________________________ (Notary Public) |
(b) Upon the proper and complete execution of a funeral planning agent designation form,
a signed notarized original thereof shall be given to the principal executing the
form, the primary funeral planning agent, and the alternate funeral planning agent,
if any.
(c) The principal is encouraged to review in detail his or her specific wishes regarding
the nature of the funeral goods and services to be provided, the manner in which funeral
services are to be conducted, and/or the disposition of his or her remains with their
funeral planning agent(s).
(d) This chapter shall not be construed to prohibit the participation of other individuals
in the funeral planning process as well as the funeral itself. No individuals shall
be required to designate a funeral planning agent under the provisions of this chapter.