[Version of this document in Word]

-DRAFT‑

Information and Instructions on Health Care Decisions and Final Affairs
Mt. Toby Friends Meeting

Name:� _________________________

Address: _________________________�������

Social Security number: _________________________

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I do ____ do not ____ have a Durable Power of Attorney for Health Care Decisions.

I have ____ have not ____ completed organ donor forms.

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A copy of my Power of Attorney can be found at _________________________

I request that Mt. Toby Friends Meeting carry out the following upon my death:

Persons to notify immediately:

Name:� _________________________

Address: _________________________�������

Telephone: _________________________����

Relationship: _________________________

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Disposal of my Body:

(Answer yes or no, apply details as appropriate)

Bury at Mt. Toby? ____����������

Elsewhere? ____���������

Family Plot? ____�������

Name of Plot _________________________

Prepaid? If so location of Deed _________________________���������

If Member of Memorial Society _________________________��������

Address: _________________________

Telephone: _________________________����

Location of contract _________________________��

Preferred Undertaker _________________________

Address _________________________�������

Telephone _________________________����

Bury with long lasting casket? ____������

Bury with a cement crypt? ____ ����������

Bury in degradable casket? ____ ��������

Degradable wood? ____���������

Cardboard box ____��� Shroud ____��

Embalm? ____

Cremation _________________________ ���

Ashes in urn? ____������ to bury? ____� at Mt. Toby ____��������

Scatter ashes? ____����

By whom: _________________________�����

Where _________________________����������

Donation of Body to Medical School _________________________

Later remains to be buried? ____���������

Where? Mt. Toby? ________________��������� Or _________________________

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Services:

A memorial meeting at Mt. Toby? ____�����������

Flowers accepted? ____���������

In lieu of flowers donation to _________________________�

Other religious burial service wishes? ________________________���

Name of group _________________________ ��������

Contact to arrange this _________________________����������

Special instruction if death is distant from home _________________________����������

����������� __________________________________________________________________

My will and legal documents can be found _________________________�����

����������� __________________________________________________________________

If minor children survive me, my wishes for their care are _________________________

����������� __________________________________________________________________

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Information for death certificate (must agree with. legal records)

Full Legal Name _________________________�������

Present Address _________________________�������

Date of Birth _________________________�

Birthplace _________________________�����

Citizenship _________________________����

Occupation _________________________���

Title _________________________�� Employer _________________________������

Father's Full Name _________________________���

Mother 's Maiden Name _________________________�������

Date received by Mt. Toby Meeting _________________________��

Signature _________________________������