The following is the funeral planning declaration form:

Declaration made this _____ day of _______ (month, year). I, _________, being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my instructions concerning funeral services, ceremonies, and the disposition of my remains after my death.

1. (1) My body shall be:

   1. (A) _______________ Buried. I direct that my body be buried at _______________.

   2. (B) _______________ Cremated. I direct that my cremated remains be disposed of as follows:

      ________________________________________________

      ________________________________________________

   3. (C) _______________ Entombed. I direct that my body be entombed at _______________.
   4. (D) _______________ I intentionally make no decision concerning the disposition of my body, leaving the decision to my designee (as named above).

2. (2) My arrangements shall be made as follows:

   1. (A) I direct that funeral services be obtained from:

      __________________________________________________

      __________________________________________________

   2. (B) I direct that the following ceremonial arrangements be made:

      __________________________________________________

      __________________________________________________

   3. (C) I direct the selection of a grave memorial that:

      __________________________________________________

      __________________________________________________

   4. (D) I direct that the following merchandise and other property be selected for the disposition of my remains, my funeral or other ceremonial arrangements:

      _________________________________________________

      __________________________________________________

      __________________________________________________

      __________________________________________________

   5. (E) __________________I direct that my designee (as named above) make all arrangements concerning ceremonies and other funeral services.

3. (3) In addition to the instructions listed above, I request the following:

   __________________________________________________

   __________________________________________________

4. (4) If it is impossible to make an arrangement specified in subdivisions (1) through (3) because:

   1. (A) a funeral home or other service provider is out of business, impossible to locate, or otherwise unable to provide the specified service; or

   2. (B) the specified arrangement is impossible, impractical, or illegal;

      I direct my designee to make alternate arrangements to the best of the designee's ability.

      It is my intention that this declaration be honored by my family and others as the final expression of my intentions concerning my funeral and the disposition of my body after my death. I understand the full import of this declaration.

I hereby declare and direct that after my death __________________(name of designee) shall, as my designee, carry out the instructions that are set forth in this declaration. If my designee is unwilling or unable to act, I nominate ____________ as an alternate designee.

I hereby declare and direct that after my death the following actions be taken (indicate your choice by initialing or making your mark before signing this declaration):

The declarant is personally known to me, and I believe the declarant to be of sound mind. I did not sign the declarant's signature above for or at the direction of the declarant. I am not a parent, spouse, or child of the declarant. I am not entitled to any part of the declarant's estate. I am competent and at least eighteen (18) years of age.

Witness _______________ Date __________

Witness _______________ Date __________

As added by P.L.143-2009, SEC.14.