Financial Assistance requested    

I, _____________________________________ , being now of sound mind and body, hereby authorize Life Termination Facility, the organization I have authorized to destroy the pre-born baby now residing within my womb, to dispose of the body, or the parts thereof, in the following manner as indicated by my initials. I authorize, by limited power of attorney, the medical doctor who has terminated the life of my baby or babies and removed him, her or them from my body to fill in all release forms, death certificate(s) and other disposal forms which may now or hereafter be required by municipal, county, state and/or federal agencies: (Sign)___________________________

The names I have thoughtfully considered and selected to be used on such forms or certificates are: (if a boy) _______________________ (if a girl) _______________________

Disposal by cremation? _________ If disposal by incineration has been selected I desire to select the URN which will hold the ashes of the baby(s): _________ I leave the choice to the funeral director: _________ I (do / do not) desire to keep the ashes (remains) of my baby with me at home. (If not) The name of the cemetery or other place desired⁽¹⁾ for the repose of the remains is: ___________________________________________________________

* I select the following funeral parlor to handle all arrangements and funeral services:
___________________________________________ * I (do / do not) desire to have religious funeral services for my baby(s). * (If so) The name of the church is: ______________________ _________________________________ * The denomination is ______________ The name of the preacher I prefer to have is: __________________________________ * I desire to have ______ day(s) for a period of wake and mourning before interment.

Disposal by burial in an 'as is' condition following abortion: _________ (If so) * The name of the cemetery, mausoleum or other burial sight¹ I have selected is: _______________ _____________________________________ * I (do / do not) desire to view the remains of my baby before burial. * I (do / do not) desire to have the baby's(s) remains open for viewing prior to burial. (If so) * The funeral parlor I have chosen is: ____________________________________________ * Phone No: ________________

* My religious preference for burial service is: ________________________________

* I prefer to use the following minister, priest or rabbi: __________________________

* City: ________________________ * State: ______ * Phone No: _______________

Disposal by burial of reassembled baby(s) body parts following its death: _________ (If so please answer above indicated (*) questions). If so I want a (simple / complex) reassembly of parts (attempt at full restoration of original appearance): _________

(Note: Total reassembly or restoration of baby is not possible when parts are crushed, badly damaged or all parts cannot be found or recognized).

Disposal by sending to a dissection and experimentation facility (receiving business to determine the final disposition of remains without need for burial services or of knowing how or where baby/babies  is/are  disposed): _________

Disposal by use of body organs and tissues in cosmetics or for other miscellaneous use at the direction of clinic terminating the life of my unborn baby: _________ (Profits from this method of disposal will be disbursed at the discretion of the clinic).

Disposal by insertion into specially designed (for grinding up skull bones) oversized garbage disposal (most commonly used method for disposal). The ground up body of my baby is then to be flushed into the common city "sewer" system, the equivalent of flushing my baby down the toilet: _________

Disposal by placing of baby's (or babies') body or body parts into trash or waste disposal dumpster (more often used for late term abortions) and brought to "locally approved" garbage dump: __________

I desire to have the following person or persons notify my children (if any) of my decision to have the life of their brother or sister terminated: (circle one) Myself - Husband - Pastor - Terminating Doctor - Other: __________________________. The following are my well thought out reasons for my wanting to have my child's life terminated: _______________________________________________________________

My date of birth is: ____________________. I swear by whatever is holy and sacred to me that I have received my husband's, parent's, guardian's, pastor's or judge's consent and that the signature on the attached form is his or her signature: _________

I swear that the "father of the child or children" to be terminated agrees to his, her or their killing and that the signature below is truly his: _________

I hereby solemnly affirm that I have asked or have had the opportunity to ask the FOR PROFIT LIFE TERMINATION COUNSELOR all the questions which have come to my mind with due reflection on the full consequences of my consent in the termination, the killing of the human life, my baby, which is ' now ' residing within me: _________

I hereby assert and certify that I do now and will forever hold harmless the agency and staff who assisted me in the murder of my child or children: _________

I solemnly affirm that I have had three (3) full days following full disclosure of the content of these two (2) forms as is generally required by law for binding contractual agreements to become valid: _________

I acknowledge that this form and all attachments hereto will be a matter of public record and that the information contained herein and attached may be compiled for use as statistical data to illustrate the incapacity of women in these circumstances to make sound decisions which they will be able to happily live with the rest of their lives.

1. Private personal burial of your baby (with dignity) may be in
   places usually reserved for family pets.

           
   "RESEARCH"             "Substitutional Burial"            "Medical Experimentation"

mother's signature: _____________________ SSN: _____________ Driver or I.D. # ____________

father's signature: _____________________ SSN: _____________ Driver or I.D. # ____________

Signature of 1st witness: _____________________

Signature of 2nd witness: _____________________

                         

Notary: ______________________________ Date: _______________________

© Copyright 1989 by "Life Enterprises Unlimited", PO Box 850307, Mobile, AL 36685
© Copyright 1997 -- May be used with permission.
May not be used to raise funds or to be sold.

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LIFE ENTERPRISES UNLIMITED
           (A 501-c-3 Non-Profit Organization)
    P. O. Box 850307
    Mobile, AL  36685        U. S. A.