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Right to Control Disposition Waiver

2. McLennan County Health Services Waiver of Right to Control Disposition
   Please do not complete this form without being instructed by the county staff. Call 254-757-5174 should you need assistance.

   Please do not complete this form without being instructed by the county staff. Call 254-757-5174 should you need assistance.

4. The undersigned*

   Legal Next of Kin

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

   Deceased Name

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

   Enter Relationship to Deceased

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

   Enter name and relationship separated by comma of the designated person

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 Decedent 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. Name of Person Waiving the Rights*

    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. Email Address

23. Phone Number*

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

    Signature

26. Date*
    Date

    Enter date

Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

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