154.30(8)(f)(f) The department shall prepare and provide copies of the authorization for final disposition form and accompanying information for distribution in quantities to funeral directors, crematory authorities, cemetery authorities, hospitals, nursing homes, county clerks, and local bar associations and individually to private persons. The department shall include, in information accompanying the authorization for final disposition form, at least the statutory definitions of terms used in the form, and an instruction to potential declarants to read and understand the information before completing the form. The department may charge a reasonable fee for the cost of preparation and distribution. The authorization for final disposition form distributed by the department shall be easy to read, in not less than 10-point type, and in the following form: AUTHORIZATION FOR
FINAL DISPOSITION
I, .... (print name and address), being of sound mind, willfully and voluntarily make known by this document my desire that, upon my death, the final disposition of my remains be under the control of my representative under the requirements of section 154.30, Wisconsin statutes, and, with respect to that final disposition only, I hereby appoint the representative and any successor representative named in this document. All decisions made by my representative or any successor representative with respect to the final disposition of my remains are binding.
Name of representative
Address
Telephone number
If my representative dies, becomes incapacitated, resigns, refuses to act, ceases to be qualified, or cannot be located within the time necessary to control the final disposition of my remains, I hereby appoint the following individuals, each to act alone and successively, in the order specified, to serve as my successor representative:
1. Name of first successor representative
Address
Telephone number
2. Name of second successor representative
Address
Telephone number
Suggested special directions
Suggested instructions concerning religious
observances
Suggested source of funds for
implementing final disposition
directions and instructions
This authorization becomes effective upon my death.
I hereby revoke any prior authorization for final disposition that I may have signed before the date that this document is signed.
I hereby agree that any funeral director, crematory authority, or cemetery authority that receives a copy of this document may act under it. Any modification or revocation of this document is not effective as to a funeral director, crematory authority, or cemetery authority until the funeral director, crematory authority, or cemetery authority receives actual notice of the modification or revocation. No funeral director, crematory authority, or cemetery authority may be liable because of reliance on a copy of this document.
The representative and any successor representative, by accepting appointment under this document, assume the powers and duties specified for a representative under section 154.30, Wisconsin statutes.
Signed this day of
Signature of declarant
I hereby accept appointment as representative for the control of final disposition of the declarant’s remains.
Signed this day of
Signature of representative
I hereby accept appointment as successor representative for the control of final disposition of the declarant’s remains.
Signed this day of
Signature of first successor representative
Signed this day of
Signature of second successor
representative
I attest that the declarant signed or acknowledged this authorization for final disposition in my presence and that the declarant appears to be of sound mind and not subject to duress, fraud, or undue influence. I further attest that I am not the representative or the successor representative appointed under this document, that I am aged at least 18, and that I am not related to the declarant by blood, marriage, or adoption.
Witness (print name)
Signature
Address
Date
Witness (print name)
Signature
Address
Date
State of Wisconsin
County of
On (date) , before me personally appeared (name of declarant) , known to me or satisfactorily proven to be the individual whose name is specified in this document as the declarant and who has acknowledged that he or she executed the document for the purposes expressed in it. I attest that the declarant appears to be of sound mind and not subject to duress, fraud, or undue influence.
Notary public
My commission expires
154.30(8m)(8m) Remote execution. For purposes of sub. (8) (d) 2., “witnessed by” and “in the presence of” include the simultaneous remote appearance by 2-way, real-time audiovisual communication technology if all of the following conditions are satisfied: 154.30(8m)(a)(a) The signing is supervised by an attorney in good standing licensed by this state. The supervising attorney may serve as one of the remote witnesses. 154.30(8m)(b)(b) The declarant attests to being physically located in this state during the 2-way, real-time audiovisual communication. 154.30(8m)(c)(c) Each remote witness attests to being physically located in this state during the 2-way, real-time audiovisual communication. 154.30(8m)(d)(d) The declarant and each of the remote witnesses identify themselves. If the declarant and remote witnesses are not personally known to each other and to the supervising attorney, the declarant and each of the remote witnesses display photo identification. 154.30(8m)(e)(e) The declarant identifies anyone else present in the same physical location as the declarant and, if possible, the declarant makes a visual sweep of the declarant’s physical surroundings so that the supervising attorney and each remote witness can confirm the presence of any other person. 154.30(8m)(f)(f) The declarant displays the authorization for final disposition, confirms the total number of pages and the page number of the page on which the declarant’s signature will be affixed, and declares to the remote witnesses and the supervising attorney all of the following: 154.30(8m)(f)2.2. That the document is an authorization for final disposition. 154.30(8m)(g)(g) The declarant, or an individual 18 years of age or older at the express direction and in the physical presence of the declarant, dates and signs the authorization for final disposition in a manner that allows each of the remote witnesses and the supervising attorney to see the execution. 154.30(8m)(h)(h) The audiovisual communication technology used allows communication by which a person is able to see, hear, and communicate in an interactive way with another person in real time using electronic means, except that if the declarant, a remote witness, or the supervising attorney has an impairment that affects hearing, sight, or speech, assistive technology or learned skills may be substituted for audio or visual if it allows that person to actively participate in the signing in real time. 154.30(8m)(i)(i) The authorization for final disposition indicates that it is being executed pursuant to this subsection. 154.30(8m)(j)1.1. The declarant, or another person at the direction of the declarant, personally delivers or transmits by U.S. mail or commercial courier service the entire signed original authorization for final disposition to the supervising attorney within a reasonable time after execution. The supervising attorney then personally delivers or transmits by U.S. mail or commercial courier service the entire signed original authorization for final disposition to the remote witnesses within a reasonable time. The first remote witness to receive the original authorization for final disposition signs and dates the original authorization for final disposition as a witness and forwards the entire signed original authorization for final disposition by personal delivery or U.S. mail or commercial courier service within a reasonable time to the 2nd remote witness, who signs and dates it as a witness and forwards the entire signed original authorization for final disposition by personal delivery or U.S. mail or commercial courier service within a reasonable time to the supervising attorney. 154.30(8m)(j)2.2. The declarant, or another person at the direction of the declarant, personally delivers or transmits by U.S. mail or commercial courier service the entire signed original authorization for final disposition to the supervising attorney within a reasonable time after execution, and transmits by facsimile or electronic means a legible copy of the entire signed authorization for final disposition directly to each remote witness within a reasonable time after execution. Each remote witness shall then sign the transmitted copy of the authorization for final disposition as a witness and personally deliver or transmit by U.S. mail or commercial courier service the entire signed copy of the authorization for final disposition to the supervising attorney within a reasonable time after witnessing. The signed original and signed copies together shall constitute one original document, unless the supervising attorney, within a reasonable time after receiving the signed original and signed copies, compiles the signed original and signed copies into one document by attaching the signature pages of each remote witness to the original signed by or on behalf of the declarant, in which case the compiled document shall constitute the original. 154.30(8m)(j)3.3. The declarant and each of the remote witnesses sign identical copies of the original. The declarant, or another person at the direction of the declarant, and each of the remote witnesses personally deliver or transmit by U.S. mail or commercial courier service the signed originals to the supervising attorney within a reasonable time after execution. All of the signed originals together shall constitute one original document unless the supervising attorney, within a reasonable time after receiving all signed originals, compiles the originals into one document by attaching the signature pages of each remote witness to the original signed by the declarant, in which case the compiled document shall constitute the original. 154.30(8m)(k)(k) The supervising attorney completes an affidavit of compliance that contains the following information: 154.30(8m)(k)2.2. The name and residential or business address of each remote witness. 154.30(8m)(k)3.3. The address within this state where the declarant was physically located at the time the declarant signed the authorization for final disposition. 154.30(8m)(k)4.4. The address within this state where each remote witness was physically located at the time the remote witness witnessed the declarant’s execution of the authorization for final disposition. 154.30(8m)(k)5.5. A statement that the declarant and remote witnesses were all known to each other and the supervising attorney or a description of the form of photo identification used to confirm the identity of the declarant and each remote witness. 154.30(8m)(k)6.6. Confirmation that the declarant declared that the declarant is 18 years of age or older, that the document is the declarant’s authorization for final disposition, and that the document was being executed as the declarant’s voluntary act. 154.30(8m)(k)7.7. Confirmation that each of the remote witnesses and the supervising attorney were able to see the declarant, or an individual 18 years of age or older at the express direction and in the physical presence of the declarant, sign, and that the declarant appeared to be 18 years of age or older and acting voluntarily. 154.30(8m)(k)8.8. A description of the audiovisual technology used for the signing process. 154.30(8m)(k)9.9. If the authorization for final disposition was not signed in counterpart, a description of the method used to forward the authorization for final disposition to each remote witness for signing and to the supervising attorney after signing. 154.30(8m)(k)10.10. If the authorization for final disposition was signed in counterpart, a description of the method used to forward each counterpart to the supervising attorney and, if applicable, how and when the supervising attorney physically compiled the signed paper counterparts into a single document containing the authorization for final disposition, the signature of the declarant, and the signatures of the remote witnesses. 154.30(8m)(k)11.11. The name, state bar number, and business or residential address of the supervising attorney. 154.30(8m)(k)12.12. Any other information that the supervising attorney considers to be material with respect to the declarant’s capacity to sign a valid authorization for final disposition, the declarant’s and witnesses’ compliance with this section, or any other information that the supervising attorney deems relevant to the execution of the authorization for final disposition. 154.30(8m)(L)(L) The affidavit of compliance is attached to the authorization for final disposition. 154.30(8m)(m)(m) An affidavit of compliance described in this subsection shall be substantially in the following form: AFFIDAVIT OF COMPLIANCE
State of ....
County of ....
The undersigned, being first duly sworn under oath, states as follows:
This Affidavit of Compliance is executed pursuant to Wis. Stat. § 154.30 (8m) to document the execution of the authorization for final disposition of [name of declarant] via remote appearance by 2-way, real-time audiovisual communication technology on [date]. B1. The name and residential address of the declarant is ....
2. The name and [residential or business] address of remote witness 1 is ....
3. The name and [residential or business] address of remote witness 2 is ....
4. The address within the state of Wisconsin where the declarant was physically located at the time the declarant signed the authorization for final disposition is ....
5. The address within the state of Wisconsin where remote witness 1 was physically located at the time the remote witness witnessed the declarant’s execution of the authorization for final disposition is ....
6. The address within the state of Wisconsin where remote witness 2 was physically located at the time the remote witness witnessed the declarant’s execution of the authorization for final disposition is ....
7. The declarant and remote witnesses were all known to each other and to the supervising attorney. - OR - The declarant and remote witnesses were not all known to each other and to the supervising attorney. Each produced the following form of photo identification to confirm his or her identity:
