I, _____________________________________, have arranged for an insurance policy underwritten by _________________________________ with Summum designated as the owner of the policy and named as the beneficiary. This is my donation to Summum.

The policy number is: ____________________________.

The amount of the policy is: _____________________.

I desire that Summum, at the time of my death, arrange for and conduct the rites of my Mummification and Transference.

________________________________________
Declarant

______________________________________________________________________
Address

______________________________________________________________________
City, State, Zip

________________________________________
Phone

________________________________________
Next of Kin

________________________________________
Witness

_____________________________
Date