(755 ILCS 65/10)

Sec. 10. Form. The written instrument authorizing the disposition of remains under paragraph (1) of Section 5 of this Act shall be in substantially the following form:

"APPOINTMENT OF AGENT TO CONTROL DISPOSITION OF REMAINS I, ................................, 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 named below) and, with respect to that subject only, I hereby appoint such person as my agent (attorney-in-fact). All decisions made by my agent with respect to the disposition of my remains, including cremation, shall be binding.

SPECIAL DIRECTIONS:

Set forth below are any special directions limiting the power granted to my agent:

..............................

..............................

..............................

If the disposition of my remains is by cremation, then:

( ) I do not wish to allow any of my survivors the option of canceling my cremation and selecting alternative arrangements, regardless of whether my survivors deem a change to be appropriate.

( ) I wish to allow only the survivors I have designated below the option of canceling my cremation and selecting alternative arrangements, if they deem a change to be appropriate:

......................................................

......................................................

......................................................

ASSUMPTION:

THE AGENT, AND EACH SUCCESSOR AGENT, BY ACCEPTING THIS APPOINTMENT, AGREES TO AND ASSUMES THE OBLIGATIONS PROVIDED HEREIN. AN AGENT MAY SIGN AT ANY TIME, BUT AN AGENT'S AUTHORITY TO ACT IS NOT EFFECTIVE UNTIL THE AGENT SIGNS BELOW TO INDICATE THE ACCEPTANCE OF APPOINTMENT. ANY NUMBER OF AGENTS MAY SIGN, BUT ONLY THE SIGNATURE OF THE AGENT ACTING AT ANY TIME IS REQUIRED.

AGENT:

Name: ......................................

Address: ...................................

Telephone Number: ..........................

Signature Indicating Acceptance of Appointment: .........

Date of Signature: .........................

SUCCESSORS:

If my agent dies, is determined by a court to be under a legal disability, resigns, or refuses to act, I hereby appoint the following persons (each to act alone and successively, in the order named) to serve as my agent (attorney-in-fact) to control the disposition of my remains as authorized by this document:

1. First Successor

Name: ......................................

Address: ...................................

Telephone Number: ..........................

Signature Indicating Acceptance of Appointment: .........

Date of Signature: ....................

2. Second Successor

Name: ......................................

Address: ...................................

Telephone Number: ..........................

Signature Indicating Acceptance of Appointment: .........

Date of Signature: .............

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.

RELIANCE:

I hereby agree that any hospital, cemetery organization, business operating a crematory or columbarium or both, funeral director or embalmer, or funeral establishment who receives a copy of this document may act under it. Any modification or revocation of this document is not effective as to any such party until that party receives actual notice of the modification or revocation. No such party shall be liable because of reliance on a copy of this document.

Signed this ...... day of .............., ...........

.........................................

STATE OF ..................

COUNTY OF .................

BEFORE ME, the undersigned, a Notary Public, on this day personally appeared ...................., proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the foregoing instrument and acknowledged to me that he/she executed the same for the purposes and consideration therein expressed.

GIVEN UNDER MY HAND AND SEAL OF OFFICE this ..... day

of ................, 2........

..........................................

Printed Name: .............................

Notary Public, State of ...................

My Commission Expires:

....................".

(Source: P.A. 99-143, eff. 7-27-15.)