FUNERAL PLANNING DECLARATION Declaration made this ____

FUNERAL PLANNING DECLARATION

Declaration made this _____ day of _______, 20___ (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.

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):

(1) My body shall be:

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

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

______________________________________________________________________________

_______________________________________________________________________________

(D) _______________ I intentionally make no decision concerning the disposition of my body,

leaving the decision to my designee (as named above).

(2) My arrangements shall be made as follows:

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

_______________________________________________________________________________

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

_______________________________________________________________________________

(D) I direct that the following merchandise and other property be selected for the disposition of my

remains, my funeral or other ceremonial arrangements: __________________________________

________________________________________________________________________________

______________________________________________________________________________

(E) __________________I direct that my designee (as named above) make all arrangements

concerning ceremonies and other funeral services.

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

______________________________________________________________________________

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

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(A) a funeral home or other service provider is out of business, impossible to locate, or otherwise

unable to provide the specified service; or

(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.

Signed _______________________________________________

Name Printed _________________________________________

City, County, and State of Residence _______________________________________________

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 __________

Indiana Code 29-2-19

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

Revocation IC 29-2-19-14

Sec. 14. A declaration may be revoked by the declarant in writing or by burning, tearing, canceling, obliterating, or

destroying the declaration with the intent to revoke the declaration.

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

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