McCOY & HARRISON
FUNERAL HOME, INC.  

4918 Martin Luther King Blvd.• Houston, TX 77021  
Phone (713) 659-7618 • Fax (713) 748-7122  
www.mccoyandharrison.com  

State of Texas  

County of Harris  

Before Me, the undersigned authority, on this date, personally appeared the undersigned  Affiant who after being duly sworn by me did deposeth and sayeth:  

I, ,

Am the of  

Race:    Sex:   Age:  

I HEREBY authorize McCoy & Harrison Funeral Home, Inc:  

To Recover the body of the deceased from , and direct  McCoy and Harrison Funeral Home to transport the remains of the deceased to their location at  4918 Martin Luther King Blvd. Houston, TX 77021.  

The undersigned Affiant acknowledges that he/she is the legal next of kin and authorizes the above funeral home to release the decedent and all his or her personal effects in possession. I (We) do agree to indemnify and hold harmless all funeral home parties from any and all loss, costs, actions, or damage which they may suffer as a result of such said release.  

Affiant
Please sign at the bottom part of this document.

Witness
Please sign at the bottom part of this document.

This Instrument was sworn to and subscribed before me this September 27, 2026

(SEAL} Notary Public in and for Harris County, Texas