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Right to Control Disposition Waiver

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

  2. Enter Name

  3. Enter Name

  4. Enter Relationship

  5. Enter name and relationship separated by comma

  6. Enter name

  7. 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.

  8. 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.

  9. 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.

  10. 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.

  11. Signature of Responsible Party/Applicant

  12. Enter date

  13. Leave This Blank:

  14. This field is not part of the form submission.