Thibadeau Mortuary Service, p.a.

124 E. Diamond Avenue, Gaithersburg, Maryland 20877

www.InterFaithFunerals.com
(301) 495-4950

Appointment of Agent to Carry Out Disposition

1. Parties:

“FUNERAL HOME”: Thibadeau Mortuary Service, P.A.

Kazadi Djo Kapiamba
“REPRESENTATIVE”:
Evariste M Kapiamba
“DECEDENT”:
Jean M kadima schimpa
“AGENT”:

2. Relationship of Representative: The REPRESENATIVE warrants and represents to the FUNERAL HOME that the
relationship between the REPRESENATIVE and the DECEDENT is as follows:
(Initial)

Relationship to DECEDENT: Adult son

3. Authority of Representative: The REPRESENATIVE warrants and represents to the FUNERAL HOME that the
REPRESENTATIVE is the person or the appointed agent of the person who by law has the paramount right to arrange and
direct the disposition, including cremation, of the remains of the DECEDENT and that no other person(s) has a superior
right over the right of the REPRESENTATIVE.
4. Appointment of Agent: The REPRESENTATIVE hereby appoints the AGENT to arrange and direct the disposition,
including cremation, of the remains of the DECEDENT, granting and relinquishing to said AGENT all of the powers and
authority that the REPRESENTATIVE has.
5. Indemnification: The REPRESENTATIVE agrees to indemnify and hold harmless the FUNERAL HOME from any claims
or causes of action arising or related in any respect to this appointment of agent to carry out right of disposition or the
FUNERAL HOME’s reliance thereon.
12 / 11 / 1995
Signature: Date:
Kazadi Djo Kapiamba Adult son
Name of Representative: Relation:
Avenue môle, n•2918 Commune lemba
Address:
Kinshasa RDC 1012

Phone: 243 8184 81175

Name of Agent: Jean M Kadima schimpa

Address: _

+19179694181
Phone:

Notary:

Please upload a photo of your ID: 36462124-0975…

Document Ref: HVEQE-APSDB-H5HUE-ECU2C Page 1 of 1

Signature Certificate
Reference number: HVEQE-APSDB-H5HUE-ECU2C

Signer Timestamp Signature

Kazadi Kapiamba
Email: djokazadi51@gmail.com

Sent: 02 Nov 2022 16:59:53 UTC

Viewed: 04 Nov 2022 09:35:40 UTC
Signed: 04 Nov 2022 09:41:57 UTC

Recipient Verification:
✔Email verified 04 Nov 2022 09:35:40 UTC IP address: 169.159.212.207

Document completed by all parties on:

04 Nov 2022 09:41:57 UTC

Page 1 of 1

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