FACSIMILE

CASE NO. 96-D-217

10_ pages with cover sheet
Transmitted October 28th, 2008
From: Claudine Dombrowski Fax: 888.330.2059 Phone: 785.845.3417 to:   Judge David Debenham Fax: (785) 291-4917 Clerk of the District Court [Please file on court record- Case No. 96-D-217] Fax: (785) 291-4908 Domestic Filings Fax: (785) 291-4911

Courtesy Copies: Governor [grants], Dorthy Halley Attorney Generals Office, Jacquie Spradling [KS Domestic Violence task Force], Battered Women’s Justice Project, Sandy Barnett, Kansas Coalition Against Sexual Assault Domestic Violence; Battered Women’s Task Force, KOVA, Sen.Vicki Schmidt, Rep: Jim Morrison Sen. Derek Schmidt, Sen. Jan Pauls, Family Court Reform Coalition, StopFamilyViolence.org, Jackie Williams, Battered Mothers Custody Conference.

Claudine Dombrowski
PO Box 4974, Topeka, Kansas 66604 (785) 845-3417 Respondent, Pro Se

IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS DIVISION THIRTEEN

In the Matter of the Marriage of; HAL RICHARDSON and; Case No. 96-D-217 CLAUDINE DOMBROWSKI ___________________________ Pursuant to K.S.A. CHAPTER 60

MOTION FOR TEMPOARY ORDER ALLOWING MINOR CHILD TO ATTEND HER GRANDMOTHERS FUNERAL

COMES NOW Respondent/Mother and requests an Order allowing minor child to attend her maternal grandmothers memorial services the weekend of Friday November 7th, after school through Sunday evening, November 9th, 2008. Just curious why don’t you write their names, like Rikki Dombrowski (born December 12, 1994) and hereinafter referred to as “our daughter”) and your Betty Sales- Stumpf (hereinafter referred to as “grandmother”.) In support: 1. Minor child’s grandmother passed away late Thursday night October 23rd 2008 in her home in Dallas, Texas. 2. Minor child had knowledge of her grandmother’s terminal illness and again when a motion was made to court for a visit with minor child and her grandmother at (safe visit) as this would be the last time grandmother’s health would allow her to travel.

5. Minor child had been extremely close to her grandmother and all her maternal familyuntil after the custody switch when all contact was denied and/or supervised allowed for mother. 6. The services will be in Great Bend, Kansas tentatively set for November 8th, 2008 at Saint Rose church.

7. This will be a dual memorial as grandmother’s husband passed away Feb 12, 2008. 8. The minor child now age fourteen years (December 12, 2007.) will have again an opportunity to see most all her nieces, cousins, great aunts and more from across the nation- to which she has been denied – all acc maternal family over the course of the past decade by ex-parte orders. 9. Lacey, the minor child’s dog (since age 2) out-lived both, her grandmother and her grandfather- and as such 'Lacey’ will be coming back with minor child and her mother after the services and will stay with mother allowing minor child to have at least some time with her pet in her late years. 10. There exists a hearing the following week November 13, 2008, to address, rule and to cease the current ex-parte orders forced upon daughter and mother this past nine years.

WHEREFORE, Mother/Respondent requests that a temporary order be entered for the weekend of November 7th thru November 9th, 2008, in the best interest of our daughter.

Respectfully Submitted,

IN THE DISTRICT COURT OF SHAWNEE COUNTY, KANSAS DIVISION THIRTEEN

In the Matter of the Marriage of; HAL RICHARDSON and; CLAUDINE DOMBROWSKI ___________________________

Case No. 96-D-217

ORDER 1. The Respondent/Mother will pickup the minor child/her daughter on Friday November 7th after school and at her school Shawnee Heights Middle School, Tecumseh, Kansas. 2. Respondent will with her daughter drive to Great Bend Kansas where they both will attend the memorial services of the minor Childs Maternal grandmother and grandfather. 3. Both Respondent and Petitioner shall have current telephonic communication. 4. Minor child shall maintain with her (and is currently in her use) -her own mobile cell provided by her mother, 5. The respondent will bring her daughter back to Odyssey on Sunday evening November 9th, 2008 where an odyssey staff OR the Petitioner’s ‘agent’ or girlfriend Ms. Julie Miller (who has been the ‘primary’ person on all transfers this past five years) will then pick up minor child from the care and control of her mother the respondent returning all control back over to petitioner. 6. The Courts scheduled hearing for ‘Motion of Justice’ remains set for November 13th, 2008 at 9:00 a.m , all parties are expected to attend forthwith..

It is so ordered on this _____of October, 2008.

_______________________ Judge David Debenham

CERTIFICATE OF SERVICE

MOTION FOR TEMPOARY ORDER ALLOWING MINOR CHILD TO ATTEND HER GRANDMOTHERS FUNERAL I the undersigned hereby certify that on the 28th day of October, 2008, served a true and correct copy of the above and foregoing pleading;, with the Clerk of the District Court, Judge Debenham, and Domestic Filings, 200 SE 7th Street, Topeka, Kansas 66603, by facsimile in accordance with Supreme Court Rule 119(b)(3) and sent a copy of the forgoing document, by U.S. Mail, postage prepaid to:

Don Hoffman 100 E. 9th Street Topeka, KS 66612

Jill Dykes 1243 SW Topeka Blvd. Topeka, KS 66612

Cc: Roger Scurlock- BSRB; Governor [grants], Dorthy Halley [executor of grants] Attorney Generals Office, Jacquie Spradling [KS Domestic Violence task Force], Battered Women’s Justice Project, Kansas Coalition Against Sexual Assault Domestic Violence; Shawnee County District Attorneys Office’s, Battered Women’s Task Force, KOVA, Sen. Vicki Schmidt, Rep: Jim Morrison, Sen. Derek Schmidt, Sen. Jan Pauls [Judiciary Cmtee]Family Court Reform Coalition, StopFamilyViolence.org, Jackie Williams, Battered Mothers Custody Conference, Odyssey Program- Topeka

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MAKiNG A FAI..-S!: 5TATt,\te"NT IN THIS FOP.:M CAN
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WA~NING:; THE PENALTY FOR KNOWINul.Y ANDA FINE OF UP TO $10,O(IO_IHEALf~

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(;UlJE. (;HAPTER 195. SEC_'95003)

IDENTIFICATION OF DECEASED PRIOR TO CREMATION PART 1 TO BE COMPLETED BY FUNERAL THERE IS NO VISUAL IDEN-r IFICATION
NAME OF DECEASED Betty Gail Sales-Stumpf

HOME REPRESENTATIVE

WHENEVER

REASON VISUAL IDENTiCATION

NOT PERFORMED
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FamjJy alit of town
DESCRIBE ALTERNATIVE (EG PHOTOGRAPHS, METHODS

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SCARS, TAnOOS) County Medical Examiner's O~:""_n

Identification

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NAME OF INDIVIDUAL INFORMATION

PROVIDING drivers i1ceD~~_~~uesteq CONFIRMING iDENTIFICATION

Claudine Dombrowskl-

NAME OF FUNERAL
Robert Sheffield

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PART II AUTHORIZED

TO BE COMPLETED BY NEX}-6F PERSON MAKING ARRANGEMENTS.

KIN OR OTHER LEGALLY

I, Claudine Dombrowski THROUGH

HAVING DECLINED TO MAi<.f.: IDENTIFICATiON

ACTUAL VIEWING OF THE REMAINS OF .aettx Gail Sales-StumpL . HEREBY AGREE TO INDEMNIFY AND HOLD MARTIN OAKS CREMATORY AND Neptune Society __ AND IT'S OFFICERS, DIRECTORS, SHAREHOLDERS, AFFILIATES, AGENTS, EMPLOYEES, SUCCESSORS AND ASSIGNS HARMLESS FROM ANY AND ALL CLAIMS, LIABILITIES, DAMAGES LOSSES, SUITS OR CAUSES OF ACTION (INCLUDING ATIORNEYS' FEES AND EXPENSES OF LITIGATION) RROUGHT BY ANY PERSON, FIRM OR CORPORA.TION OR THE PERSONAL REPRESE:NIATIVE THEREOF, RELATING TO OR ARiSING OUT OF SUCH FAILURE TO IDENTIFY

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DATE SIGNED

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Texas Funeral Strvict' Com;r.J::i5ion Form HUOlb

AUTHORIZATION TO EMBALM AT FUNERAL EST ABLISH.:.\fENT OR OTHER LOCATION
Name
NaJfii

of Licensed

Funeral

Establishmeut

_NEPTl-T:"{£ pf_

SOCa:TY_~
1O-24-2008 _

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of IJI.!.:easttd

Bett:' Sales-Stnm

Date of DeatJI

The undersigned, understanding that embalming is not required by law except in cermm opecial cases, authorizes the funeral establishment to utilize a licensed facility under the same general ownership and management or use licensed embalmers as agents or independenr ';(1l1!Flclnrs nr 'i commercial embalming establl,hment to care for, embalm, and prepare the body ofthe deceased The funeral establishment accepts the responsibility of revea1t!)g, upon request, to the next-of-kin or person responsible for making final disposition arran.gem ••. nts, the name. address, and license number of the facility where embalming occurred and th" name and license numOer ofrhe embalmer and any provisional licensee or mortuary student who assisted under the embalmer's dire~: supervision_ The underSigned authorizes PU10directs Ll-jefucaal establishment, incllltimg apprentices (provisional licensees), and mortuary students under the direct supervision ofa licensed embalmer employed by the funeral establishment, and the funeral estabJishJnent\ employees. lI)dependent ,-,outracturs, and agents to cart' for, embalm and prepare the body of the decedf'nt The und"rsigned ac~~nowJedges that this anthorizatton encompasses pennissi0D to embalm at the funeral establishment or at another facility equipped for "mbalming, including a scho('! or college of mortuary science_ Date Signed Signature of ne~t-of-kiU:-~~ RespOIL~ible fo~-makingarra~gelJlents for n;;Jdisposition

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NOTE, Mortuary Students may only participate to <,mbalmiJ)g ifpHmissioD tbe possession of the Licensed Embalmer at the time oftbc pro~edure_

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If Authorizatl0n !()f emba.lming is orai, complete the t(Jlicwing Lourion of embalming di,clas"," W;l, (ii,euss.d with next-ol-kin or penon responsible for making arrangements. Authori:l9t,ou to embalm rectlved from . . _
Relationship to Decrased. . _

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If no allthori;;atioll call be obtained, complete Ihe folJowing: J hereby admo',,,ledge thal ~_____________

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_ Las made a rC;l';Q))abk effort over a >-Jame::)f Establi$hrnent period of at least th.ree hours to obtain authorization to embalm the deceased. 1 takefur respo:15tbility fOT performmg embalming witt,out penrission Ti.mes con:J.ct v,'I'll farlllly attemp[td-

Signature and Licen,e # of EmbaJm~r The undenigned, who represents the deceased, hel'cby declares fhat having the legal the above-.. uamed. 1k::rsed --~...a-:z-,-6)2C_~_~

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PAGE 2 OF 2

2. 'mplanted mechanicai or radioaotive aevioes in the remains of the Deceased .$~C1 as pacemaKe:s etc,) '~ay orea:" a hazard 'Nh"n placea 'n the c:ematlcn chamber The C'emalary wili not cre"1ate any human 'er,',,3!"Swl"8h contain any tyee of m'clanted mee'larical or radiaac!"le devce In the event the remains of the jeceased contain such a device, AA herec\ o"thorizes'JeotJ1e or:'ematorj a~d tr.e,ragans, and e~pcyees 'e 'emove dny such mecha~,cal deVices from the rerdl">S of tie .geceased pnor to cre"1a:'o1, and c,spcse ~f so~h Items allts dlsc:ei,ol:, AA HEREBY. CERTIFIES THAT THE REMAINS OF THE DECEASED [ ] DOES ORfiJ DOES NOT CONTAIN ANY TYPE OF IMPLANTED PACEMAKER. PROSTHESIS, SiLICON, MECHANICAL OR RADIOACTIVE DEVICE. Lis:ed be,OWare a,; Implante,j mechanl~1 anc/Or radloae:ve deVice, wheh Neptlne.s autrlJrizec tr] femC'VB frem the remains cfthe Deceasll(j pnortocremation a.~d c!SPOs€of as ir,:c<'ltec, If no Instruction for disPQS,ticn ISg"Jer:. such ite-s ra~ be dspoSed of at ina dlscreliOn 'Of\ep:une Desclp',Ol of Deviee' _ _ Jisposition. 3. The cremabcr container contairrng the rema!n~ of tile De';eased wi' be placee 'n ihe (;[e,"1,,:101,~hambe- and be iotaly a~,d irmversibly destroyed by w'i (J:olonged exposure to INeese heat and oirec! far.e 4 Ce1.ai1 items inCluding, but rot !imlted to, be:::ypmstreses,:ent~"'es, cert1al f!I:'"'gs arid oridge"v(;rl" ard c~~erpel.5Jra! ar1ides accarToan,-ir,g the fI2T'JI:1S 0' 'he Deceased, Will be deStroYed ducng the ciernaTion Jrocess ;\A luceneriiJ,norzes :ha; If any Hems oti,er ;hailtn. cremated rema'ns of the Deceased are re-ccvered f"cm the cre:rnatior cnamber, tney may De seDarated ;ron~ the uemaiecE-re'(jlr'lS, anc disposed ot by the Cmmatory (
5, AA IS r-esponsit}!e fO' ~em'Jv:ng ani item Of \fd:ue

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Jev.;e!ry") f:,om

rema'.0'Y fro", ary iiatty ~.

fo' their destructi~

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tIe ;,em~-"'s pncr tCI the uematiofl pmcess and ~hali hoid harmless Neptune and l'Aladng tn.s oaragraph, AA I"."et', aGknowledges ,hal no items of value were decvered w,th the

-Limanrerrams ~o~,eptune or the Crematory. ~

6. "ollow'ng c:e'71atior" the cremated re!11amsJ' the Deceased ~or,SlstlnQ pn~';l':I,~i bo{'~ i'agmenls, w':, be me~han'cally pu'venzed to an unidentifiable cans,stelcy Drier to Diacerr;ent in an urn or otr~e:"con~(L1er 7 In t""leevent tre :.;T. or container is irsL.ffic!er~ to accc~~,cd3te all of thecr8ma~e.~ fG"la:m, cf tho DE:JCE,'8Sod,any excess cremated re~nains wi:! :,e plsced in a secoGdary cowairer aild ceturned together w'th :ne prrt"a:y urn or conia.1er
8. A.A.In'Jerslar:ds and aCKnowledges that e\"'er "JJiththe ex~rcise of re3scra::;le ca'8 and It"le use of ::18 Crem;EJtorv'S test efforts, it:s nel poss:b:e to recover ~I partlc'es of 'hs cre",ated remains of tre Deceased, ard that SOrriepa'eIGie, ~av hacvertecl!y beconle commingled witn particles of ctner cremated remains ~fmaining ir ~hecren~ationchamber ~:,,<t'r;,r0ther deVices util:ze-dtc; process the crelidted re:,;)a:ns. AA fiereby authoflzes the CretTatory tD dispose of any such res,cual oa",oIe5 in any ,awful 'T,annerT deems 2pprociate i ~, Griess Aft. gives specific :"mtten ir:st:'Jctions :r1 th's Atrho~,z3tiGn, :~e crema~:o:: proceSSing an'J ijSPOSltiOfl perkrmed In accorda~ce \\'ith any par't,:,ul;r 18irgiC1us or ethr":i:: c:jslor~s of the re~~ains of the Deceased WIIi no: CIt;

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10 in the event theAA ag'ees to take c~ssess,on, and dees rJt cake posse,slon of :,1ecrwated AA autMr!Z8S and directs Neptune or CCe'TJatoryo disposeDr tr'e unciarned cremated remains t

'emairs Within days after :r,e cremalicn or an agreed date, 121 deY IT:anrer permitted unde' Texas law.
Of

Except as set fo'th herein, no warcanties. exp'essec Jr Imp'ie'j, a:e !'1ace ',,,,ptune or Cr8n'!2'.Jf)' or arv ~h . employee SIGNATURE OF AUTHORIZiNG

the" -eSDeot,ve affiliates. agents, or

AGENT(S) FOR CREMATION AND ISPOSiTION D

Facts of Death Verification
as they will appear on the Certificate of Death

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4101 Airport Freewav fort Worth, TX "61 J 7 Tel: CS1?) 838-5100 Fax: U~P)838.5400 Case No.

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STATEMENT OF Fll),"ERAL GOODS A1'ILl SER"1CES SELECTED
Charges are- cniy for those- itCTlH thaI )"OU selected or th."lt aTe rcql~irc{'L If .... afe reql1ired by I<iWor by J. (:E.'tlierery or CF.tL;:.t()r:~' "t: [{}•...•. any se !terns. the reason 15 cxplamed unde, DlSClOS1.1!IS. at right If )-'OiJ. ~ele(.ttd d funeral thai ;:;.a:-' rtll.'...IlTt ::r::.balmIT1i!k sucb ;;J.6 ~ funeral v.'lth vlf~wing. you may baH' to pay for embalmLl1g '1.'01., o d ;10t ha\'e :.:: pay tx ~mbj.;mJ.n1' you did mn J.pprm-e ;:- vou 0clc~tcd i arrangemem s~cb a.~ direct c~e~laii0c., (II" in1m~dtat€ b'UJ'1al. if we charged for e:nbe.!:"llng. tb. r.ason L5cx,la:ned 'mGGr DISClOSt'RES. L~S5 C;'i;:;,n BALA.',CL
.)[

p~ C~!illt)
Crcdn C;,ud Pa>111c:nt~, DlE NSCLOSURES If any le:gaL cflUttery. U1:req~J.ilement has requned lht: pw-chase of the items listed abl'-vc, '.\•C -,-~;::i expL:ilTI th~ l~qull~rn~ilL btlo\\ ,:,)1' any

,!

CHARGES FOR SER\1CES

SELECTED

kfio.oo
Basil Sen:ices of Funeral Dire(tN' £: S:J..ff

,'.N(

on:y fL,r th •.. ltt:fn:~ thdT. ~rt ll~eJ If the: type; {)f )~c extra items. \:ve wii1 ex?lam the reasons m \V1'1~!.r,g "n :_11~,(,intnl~t :"" th.~ t;"',"cpt V<)~l wlsh to ~0mplain I or ques-Loll S.~lYot YOw' SI';,!,\':(~S, y,:)U nu_y COiHelet u"- d =.,rou,r! Ci)D'/Crl.lc.,.',ce. [f :a:y c:orr:pl::iints can no': be rn,)l\-ed, you may also i
{-rj,1..rg,-~.;. J.-:'e IY:Jdc

fJn~r~l sd.;:c'?c

r('ql~jre$

i

(;~nt:Jcr

the

Tex<'is

FuneriOl.l

St'-f',-lCe

C(lTi~i.m)~ijj(>.n,

PO

B0X

12217.[

Ad.ditional

Transportation

AustlO, Tex3.s "J~"7Ii Tdep~1•. )r,C i:S88) 6674gb 1 Fa-\:, (51F! 479-5064 , T'-)f ,:mly \'.iJrr,'n{y (If:, th~ :;l:..-t..'h:mdi~1; 5r)j;3,~n f:OI1.n,.;;t~on ,vlth this 5fn-Kt: . lS tht' e:-:press \'Ill'1en 'Yii:f'3_.n:--:;_.:f 'lJ"Y"g-rant::-J by' th,t m.muf".::tu:-tT- TJ--JJ S ' F.\CILlTY l\L'cKES NO \\ARP_,,'','TY Of t-IERCHA'HABILlTY A'ID A':' JVYU~D WAFJIJ':'<lY Of FIT;iESS fOR A PARTICULAR l'1. RPOSf, \-V lUi RES-P::CTTO\?'\YlfER01ANDISEPC'RCHASJ:D A(DOWLEDGDlf)\T .-\.:\0 AGREE.\IE:'iT 1 herl?b:, ack~lo'.,-12jge tl)J.~ T 1~2.'.:e the If'gi-l: rig~t Or h.;lye been: ~.i-.-en pcrrni5:'lOrJ by the Ilexi k.lH to act on :J-leir behalf to ;lffange i t!lf' nni:3.: :::er\'L:~:; T'lr rh~ dect'Ci::;ed n~-!ml;"don this Stlt:m~nt. and 1\ auwunzt' Tlus IUIlerltl eS:.ablishmetl[ to ?ertiJrm ~e(\;ii.:es;, fum~~;;:h, g~l(HJ~l ::tnd lTICUr p'Jlsldc c, •...• a:-ges. sJh;~c:flf:d orr. u:.is. Statement. ! <lcknowleJge t~la: T h,l\'e rC'~::ejveJ the (~t'neral Price List and ai (;OPV of t.t::s. S:atBment e'f' ~:.lne~-a1 G{){}ds: and Sen-ji~e:s Selected.'
i

A.dditional

crematorv

fee ineXC~5S0:' YlI) :0$

TER'Vrs OF PAYME:'<T Ow' fet'.:-; .lre dUe: dr,d p~',-yah k pn{)t to completion By my sigwHure be 1m.\'.,1 l"-ereby ag;ree [0 an of the ab{)\'t edge rt:c~ipt of~. C(YP~' (1: th:s
7

of services. and $.(;kr;.,CJwli '

S~(~~C:~~"'':'::.~.

Deliv!':r). of cremated r~main.s ce!ne::ery or rt~idtntt

t()

loc,]l

paCk~S)g and shiping of cremated remains via mail

Oth~rtQ,kU\ f0Q.cl~i'Pdmlr\

~t'
~

Oth;\roD~l. Qm'tt(1;\6r-'CHARGES Cardboard FOR MERCHA'\iHSE alternative SE L Ei;'TI'D cor,:ain~r t:'icJ for cremation

PT:.R. HASER .. C --

SIGI\ATTR£

~

:'l;C'W(ls:.~---~~~~
Si.8=Tlt.~
Other ACCEPTA:"tCE:

_

Dal. Dale
~;&T:ature

.Jll. ...
'
.

OTher

~ __

._.__

.__ .__ CH.-\RGFS

T;;i:~ ::,,':.::!'~;)is-h:mcnt agJ~~s provl,ie ail ser,:ices. nJ.n(:h~'<..:jd:.st <L...-.:::i;:a.:;h a.dV;JJK:::~ lcJjt:.J.ttd ,:T; this S~..:.itcm=i1t.

TOTAL SERVlCE & :\IERCHA\'OIS£ (.T:l~S joes nut ,_llclude c<t.-"had YaTl(;(':Sl

5lli~~ti~!,Dq
3~

~~Q£l~~

:"~p:'lne Rc?rt:sem.1u',(>

_

AUTHORIZATION

FOR CREMATION AND DISj:)OSITION

NOTICE: THIS IS A LEGAL DOCUMENT, IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION REAO THIS DOCUMENT CAREFULLY BEFORE SIGNING CREMATION IS IRREVERSIBLE AND FINAL.

en. "1..

-----------------

t"-'oJ .;.J

N EFTU:\E

SOCIETYr

4101 Mport Freeway, Fort VVortt", TX 76117 ' ;>'018817-838-5'00 3425 S. Shepnerd Dnve, SUltP.'ce. Houston. TX 77098 • Phone 713-533-1690 911 W A.1derson Lane, Suite ", AJst:n, -X 78757 • Prone 512-323-0122 I/We (tha "Autno,'1zec Agent or AJ\";l the Lrce,"sigrec, cerhfy, warrant, a.ld represent thEt a:; the A.A, t\ve have full and legel righ~ ana authority! and know of no other living B1d he'eby Name person who hasa supenor p10riry "g1: unce' state Jaw to au:,orize the crenation. processing, ana tne c;soosit,or L'1e named of request and BJthonze Ire \eptune SOrlP'Y" ','\'p'Lnc ,t- tB~e oessess'on of ana "naKe arrangeme"ts for the cremation ' 0 Deceased below,

of Deceased 0' Death Ser>,ce

B~~
jQ
[ j Yes

DatetTIlTe

_

\1L6- _ __
NO; Ii

G: o
Yes

S.9ks ~ ~tl&tn Iof'

~____

__ .
M/.:
p~' Dat~ of Birth

I

,

.

II / q

ViewirrglFune'ai

l"N

Da:e

and

1'1"16

0' such

r 7

Ii q d{o

Authorzsd Agent ful1hsr autMnzes the Crematory to 08"Orm the crematlCJn and agrs-es to indemnity. reie"se. ?nd hold 1srmless NePtune and the Crematory. ard '.1F affiliates, agents, employees. reoresentah1es a1d assigns from any and ail loss da'1ages, IlabiUty, expenses WS~" or claims resulting fmm thiS AutnoriZE.LO'l (including attorneys' fees and expenses elf !it-gation) in connection V-liththe crernat!cr: anc ,jispOSIt:iY" of the crerr,atec remains of the Deceasec. or A"thor:zed possession RIGHT Agents ra,'ure to correct'y Identify arrangements AND the lemalr:s the Deceased, of disclose the presenc;; d aery imp!d'ited remains mechanica: or radioactive deVices J'••take of, or make oermanent for CISPOSltlor, of such cremated the DISPOSiTION:

TO CONTROL

THE CREMATION

Under TEXAS HE'\: TH & Sf,FEn
in

i:lwrittng for the disDositon of r,:s o~ r'er remains, :ilciuding cremation,
SUCh r:erscn, the foHo\lvmg persons. remains. ir the pnonty listed, (lave

CUD!':. ~711CC2(8) Unless a Dec~C!ent nas left directions a VVHI,a prep~;o ~~:'\e(al COr:tii1:.:: or d wfitter: instrument sigfled and adwowledged by

tr!C

n~ht to controi

tree

d;spositlon.

mciud'ng

crerqation, of lhe Decedent's remains,

shaH irter

the

a~d are liable for t~e reasonab,e costf irtermert c (1;' the Person designated '1 a writtep irstrurr:en; s:g~ed~J\j'ttie Decece •. 't :2': the Decede1ts sur,'i'ii1g spcGse: .. ~---..,...
(3)

the Decece,rs tl18 Decedents

survivi1Q sUNlving

adult childr",,; care,'ts
'J~

,,4:
'6 AA hereby AA hereby
[

(5, the Decedents slJrYlvlng .3GUlt ;3!b;lngs,
a~y 3(;J!t Derson :r. :nt? n8xt degree aL:hori2es assumes

-:j~lS''P in

';-'1\7

,xder nampc by L3\Vto Inre~!t the E.3t~te of t~e Deceden:. urn se'ected

the Cremaled Remai.cs Ie:; :Je "'<iced in th!o 'olowing 'eSPC>1Slbilltj 'or the CreClatM RemelTS ann ",,thor

N~t.M

..•"

IJ..¥#?
._~ _

?e" :he Dsp';siti'jr Reeii,;e "I

of/::Crwnared

Rem8ln'l fOllOW; as
.""_~_~

St,atteqng at Sea by Neptune ::r Neptune's u,g"rt ~ J
Release Deliver to Neptune to Cemetery 'am:ly Member Ma' _. _ io' delivery to Familv Mernber ramed

[,kf
[ I
[ ~iP ]

fEttJ/-E-- L.o E z?--S
._.~ _~_~ __. ~.~_

~:":-~-J-~-~-

~ ~ ~~ __~

Release:o

Vie U S Regls:erec Special i-strlJctons and CremalOfj and the AUlhor,zed Name

to

~~b2:~e:=[o1-~'2=~----=---_-_-_-_~- _~ '___ -~~
.__ ~. ~ .~_ __ sl11ppec Via c.:e9isterAI] cnc a:l cla,ms -------'-ei.6/lf-Maii With the Unltea csmage to c'emated lee.'oM "1arm'ess to IrOe-1m'! ariC (rcic t"er-

__ ~_~~_ ~
States Postai

[I

I 'NePtune

are net resporsbie b ary .IGSSofx Agent ag-56S

I

Serv,ee

AUI~iledAgent Arress ~::QnShlo. Tne cramat:on regulations,

Ei, y'E

LoE~'~

_!lIZ 8a.K~ __ ~

==---from ar'! contdct to De r8lrtwec

1
1

re!at2lJ to such ~hippin() -;o-ne-.

~_~
t,liscel!am,o"s

r;JY:bt:t.llT EiE)/'IJ
inforcnat:'xl' he-rein sha:: b~3pertorrncc the ruies. regulations

_-_~-._-~-,O--11--7_-~-l:---_~-0),1 S~»_ lj(; 6 l-53D
and the Crematory:

A",.J
and subject

T!EX~y.J.r;'(,'__
and dispositiJ~ io :he iollowin'g terms and condito"s.

processing,

lhtJ Dececsed adronzec
ir;il,idlng
:,m;eiS

,r a.ccordance with ali governing state and local jaws and and pOiicies of Neptune

1 The remaIns of the Deceased pro' other Ie cremation nor.C(Jmbustibie in the event materia's,

winnet be ac:;e.oted fo' crernat1c.n '~e remairs ,AA autncnzes of ttle Deceased the remares

~~ceh/8C \~,r~j;acec:

~<~ tr'(:

Crematory

:!i

c. combustio!e, cortalner
'Tlir'~f':r.

container. The Crema.::')ry isauthorized to remove and diSpO.3€

J~ handles.

O~'larr:Bn:s,ana srv ot:e~ r'!(i(i-Gombustible
by the Cremato,,! caSKet or other ,1 a prior io cremation -:.asKel '" \~i'lY ld'Ntui

:eak resistan:, rigid crematIon :lf~ms attached to tree cremation container co~structed of :'nAtal, tibe'giass cremation container, or

8te 'ece'ved

,'1 :",e D8Ceased

and If a comtJustiD!e piaced

AA ftJrthe~ .aJthcr:zes\{eptui!e

N Ci€mato~i

teJmake ::HsPOSit:O~iof any such T:nco:nDwst':D!B

\EP- TX-999-Cr~JT:ation A\.ith-l'23i07

Itt~S~CM
~ ISS

DL

04-17-2007

EXP

1r
~.

S

.SEX F HT 5-06 DOS 04-10-1965

EYES

04-10-2013 GRN WT 145

ENORS