AT THE NEED WRITTEN STATEMENT OF PERSON HAVING THE RIGHT TO CONTROL DISPOSITION

(PROVIDED TO FUNERAL DIRECTOR) PERSON OTHER THAN AGENT

Hereby represent and assert that i am entitled to control the disposition of the remains of,

I further represent that I am the person having priority to control the disposition in accordance with subdivision 2 of Section 4201 of the NYS Health Law. The order of priority set forth in subdivision 2 of Section 4201 of the NYS Health is the following:

• PERSON DESIGNATED IN WRITTEN

• STATEMENT;

• SPOUSE;

• DOMESTIC PARTNER;

• ANY CHILD 18 OR OLDER;

• ANY PARENT;

• ANY BROTHER OR SISTER;

• AUTHORIZED GUARDIAN;

• PERSON 18 OR OLDER NOW ELIGIBLE TO RECEIVE AN ESTATE DISTRIBUTION, IN THE FOLLOWING ORDER:

  • GRANDCHILDREN;

  • GREAT-GRANDCHILDREN;

  • NIECES AND NEPHEWS;

  • GRAND NIECES AND GRAND NEPHEWS;

  • GRANDPARENTS;

  • AUNTS AND UNCLES;

  • FIRST COUSINS;

  • GREAT-GRANDCHILDREN OF GRANDPARENTS;

  • SECOND COUSINS;

• FIDUCIARY;

• CLOSE FRIEND OR OTHER RELATIVES WHO IS REASONABLY FAMILIAR WITH THE DECEDENT'S WISHES, Including his or her religious beliefs, when no one on this list is available, willing, or competent to act; (NOTE: this person must complete an “At-Need Written Statement of having the right to Control Disposition” Form).

• PUBLIC ADMINISTRATOR (or the same official in a county not having a public administrator); or, anyone willing to act on behalf of the decedent who completes the “Act-Need Written Statement” Form.

I also have no knowledge that the decedent executed a will containing directions for the disposition of his or her remains or designated an agent by executing a written instrument pursuant to Section 4201 of the NYS Health Law.