Fillable Appointment of Agent to Control the Funeral and (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Appointment of Agent to Control the Funeral and (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Office of the Attorney General
Division of Consumer Aairs
New Jersey Cemetery Board
124 Halsey Street, 6th Floor, P.O. Box 45036
Newark, New Jersey 07101
(973) 504-6553
Appointment of Agent to Control the Funeral
and Disposition of Remains
In accordance with N.J.S.A. 45:27-22
General Directions For This Form
• This form creates a Funeral and Disposition Agent (“Agent”) who you appoint to authorize your funeral
arrangements and the nal disposition of your remains after your death. The appointed Agent will have
sole authority to make decisions regarding your funeral and the nal disposition of your remains.
• If you have executed a Last Will and Testament in which a person to control your funeral and disposition
is already named, execution of this form will revoke that appointment in favor of the appointment made
here. You may appoint as your Agent the same person named as Executor in your Will.
• This form must be signed by you in the presence of two (2) witnesses and a Notary. Both witnesses
must sign the completed form, and the Notary must notarize it where indicated.
• You may NOT appoint as your Agent any owner, employee, or representative of the funeral home,
cemetery or crematory you have chosen/will choose to provide any goods or services related to your
funeral and/or the disposition of your remains, unless said person is your relative.
• You may name a successor agent on this form. If your designated Agent(s) is unable or unwilling to
act, and no successor agent is named (or the named successor is unable/unwilling to act), the right to
control the funeral and disposition of your remains is determined by N.J.S.A. 45:27-22(a). The statute lists
the order of priority for the right to control as surviving spouse, then adult children, then parents, then
siblings and other next of kin.
Copies of this executed form should immediately be given to the named Agent and any other person
who should be informed of the appointment of the Agent, such as the successor agents (if any),
funeral home, cemetery or crematory, family members, estate attorney, etc.
Appointment of Agent to Control the Funeral and Disposition of Remains
I, ________________________________________________________________________________________,
(Your name, mailing address, telephone number, email address)
being an adult of sound mind, hereby willfully and voluntarily appoint ________________________________________
(Name of Designated Funeral and Disposition Agent)
New Jersey Office of the Attorney General
Division of Consumer Aairs
New Jersey Cemetery Board
124 Halsey Street, 6th Floor, P.O. Box 45036
Newark, New Jersey 07101
(973) 504-6553
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I have have not entered into a pre-need
agreement for funeral services and/or merchandise
pursuant to N.J.S.A. 45:7-82 et seq.
__________________________________________
__________________________________________
to serve as my Funeral and Disposition Agent (“Agent”), who, upon my death, shall have authority and power to
control and carry out the arrangements for my funeral and the disposition of my remains.
Prior Arrangements:
(Name and address of cemetery where you own an interment space)
I do do not own an interment space within
the cemetery below. Title to the interment space is
currently located at: ______________________
________________________________________
__________________________________________
(Name and address of funeral home with which you entered into a pre-need funeral
arrangement to provide merchandise and/or services)
Set forth below are my preferences regarding funeral arrangements and the disposition of my remains. My Agent is
not bound by the preferences stated below and may ultimately authorize arrangements and/or nal disposition that
conict with any preference listed:
Preferred Funeral Arrangements Preferred Disposition of Remains
Preferences:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Designated Funeral and Disposition Agent:
Name:_________________________________________________
Address:_______________________________________________
Telephone Number: ______________________________________
(include area code)
Email Address: _________________________________________
Successor Agent Optional:
Name:_________________________________________________
Address:_______________________________________________
Telephone Number: ______________________________________
(include area code)
Email Address: _________________________________________
I choose not to name a Successor Agent. I understand that if my designated Agent is unable or unwilling to act,
the right to control the funeral and disposition of my remains shall be governed by N.J.S.A. 45:27-22.
This form has been approved by the New Jersey Cemetery Board in accordance with N.J.S.A. 45:27-22.
Authorization:
This appointment becomes eective upon the completion and proper execution of this entire document (witnessed
and notarized). At such time, and in so doing, any previous appointment of a person to control the funeral and
disposition of my remains is hereby revoked.
In executing this form appointing a Funeral and Disposition Agent, I warrant that all representations and statements
contained in this document are true and correct and that all of the statements and signatures are made in order to appoint
a Funeral and Disposition Agent. I understand that this appointment supersedes all other priority classes outlined in
N.J.S.A. 45:27-22.
Signature of person appointing the Funeral and
Disposition Agent:
_____________________________________________
Signed this ______ day of ______________, 20 ______
Witnesses:
I declare that the person who executed this document above is personally known to me and appears to be of sound
mind and acting of his/her free will. He/She signed this document in my presence.
Witness #1: Witness #2:
Name:_____________________________________ Name:_____________________________________
Address: ___________________________________ Address: ___________________________________
City:________________ State______ Zip ________ City:________________ State______ Zip ________
Signature:__________________________________ Signature:__________________________________
Signed this _____ day of ______________, 20_____ Signed this _____ day of ______________, 20_____
Acknowledgement by Notary:
State of New Jersey, County of ______________________________________
I certify that the persons named above personally appeared before me, were conrmed and acknowledged to my
satisfaction to be the persons identied in this Appointment of Agent to Control the Funeral and Disposition of Remains,
and personally signed this document in my presence.
Signed and sworn to before me on this _____ day of ________________ , ______
Notary Signature: ___________________________________________________
Notary Name: ______________________________________________________
Expiration of Notary Commission: ______________________________________
Ax Seal
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Appointment of Agent to Control the Funeral and (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 14 August 2020

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