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Right to Control Disposition Waiver

2. McLennan County Health Services Waiver of Right to Control Disposition

4. The undersigned*

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6. being the person entitled to control the disposition of the remains of *

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7. deceased, pursuant to Section 711.002 of the Texas Health and Safety Code, and being said Decedent’s surviving*

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9. does hereby waive said rights to control the disposition of the Decedent’s remains and declines to so act. The undersigned further designates*

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11. of the Decedent as being the next priority person with the right to control the disposition of the remains of the Deceased. The statements I have made, including my answers to all questions are true and correct to the best of my knowledge and belief. I agree to give eligibility staff and the county any information necessary to prove statements regarding eligibility for pauper cremation services for the aforementioned decedent*

    Enter name

13. I understand that this is a government document and that a government agency is relying on the truthfulness of the information provided by me herein in carrying out government operations. I further understand that falsifying information on this instrument could result in criminal prosecution.

15. I further attest that I have read and understand the McLennan County Disposition of Pauper Policy, including the policy that family/survivors or others may not pay for additional services. I understand and agree that in the event any funds become available in the future, I will reimburse McLennan County the expense incurred for the funeral arrangements provided for the aforementioned deceased.

17. The undersigned agrees that any funeral establishment that receives a copy of this document may act with respect to it and shall have no liability to the undersigned because of reliance on this document.

19. Applicant Name*

    Enter name as listed on state issued driver's license or identity card. You will need to verify state issued driver's license and/or identification with Health Services upon request.

21. I declare under the penalties of perjury that the information provided herein is true and correct to the best of my personal knowledge.*

    Signature of Responsible Party/Applicant

22. Date*
    Date

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24. 1. Receive an email copy of this form.
25. Email address

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