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(Print out for future reference to give to family members)
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I, _________________________________________ wish to be cremated as my personal selection for burial rites upon death.

I request that Memorial Services be chosen as follows:
_____A Remembrance service be provided for my family members at a location of their choice.
_____ A Remembrance service be provided for my family members at my church.
_____ That no Remembrance service be provided.

Notes & Wishes:________________________________________________________________________


I request that my cremated remains be placed:
_____In the Urn I have already selected. Selection: ___________________________________
_____In the Urn I have already purchased. Location: __________________________________
_____A temporary container for scattering at a later date.
_____Keepsake containers that allow the distribution of my cremated remains among family members.
_____Whatever my family members wish to select is fine with me.

I request that the final placement of my cremated remains be:

_____The cemetery located at: _________________________________________________________

_____________________________________________ Phone: ______________________________

_____Niche_____Cemetery Space_____Mausoleum Crypt

_____Scattering in the location of my choice. Location: _________________________________

_____Another location. Location: _________________________________________________

This is not a legal document but simply a Statement of Wishes. I wish to inform my family and friends about the choices I have made and the manner in which I wish to be remembered and cared for at the time of my death. State laws may allow my family to change these instructions, but these are my wishes.



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