*** BODY RELEASE -- AUTHORIZATION AND AGREEMENT ***

SUMMUM®
707 Genesee Avenue
Salt Lake City, Utah 84104


I hereby instruct that my body be delivered after my death to a sanctuary designated by SUMMUM for the purpose of conducting the rites of my Mummification and Transference. I stipulate that such delivery be made as soon as possible, and that a copy of the Death Certificate and a Burial Transit Permit from the Department of Vital Statistics of the State of ________________ should accompany the body.

___________________________________________
Printed Name

___________________________________________
Signature

___________________________________________
Address

___________________________________________
City, State, Zip

 ___________________________________________
Date of Authorization

___________________________________________
Social Security Number

___________________________________________
Signature of Witness

___________________________________________
Address of Witness

 

STATE OF _______________ )
                         ) ss.
County of ______________ )
Subscribed, sworn to, and acknowledged before my by ________________________________________, and subscribed and sworn to before me by ________________________________________, witness, this _____ day of _______________, 20___.

My commission expires:

______________________
 ________________________________________
Notary Public, residing in _____________
County, State of _________________

IRREVOCABLE AUTHORIZATION TO BE SIGNED BY NEXT OF KIN

I IRREVOCABLY authorize the execution of the wishes indicated by this document.

___________________________________________
Signature of Next of Kin

___________________________________________
Address

___________________________________________
City, State, Zip

 ___________________________________________
Signature of Witness

___________________________________________
Date of Authorization

 

STATE OF _______________ )
                         ) ss.
County of ______________ )
Subscribed, sworn to, and acknowledged before my by ________________________________________, next of kin, and ________________________________________, witness, this _____ day of _______________, 20___.

My commission expires:

______________________
 ________________________________________
Notary Public, residing in _____________
County, State of _________________


This form must be completed in duplicate: one copy for personal file, one copy for Summum.