lUma Funeral Homes Buma Funeral Home Buma-Sargeant Funeral Home Buma Funeral Home

480 Church Street 42 Congress Street 101 North Main Street Whitinsville, Massachusetts 01588 Milford, Massachusetts 01757 Uxbridge, Massachusetts 01569

508-234-2362 508-473-5511 508-278-2755

INSURANCE PROCEEDS ASSIGNMENT

For value received and for the funeral services and burial or other disposition of the body of

(the insured), I hereby assign and transfer to

, the sum of dollars (Name of Funeral Home)

($ ) or so much thereof as is available from the proceeds of Policy Number

of the

Insurance Co. which is due me as beneficiary, or by reason of some other qualification.

I hereby instruct and authorize the Insurance Co.

to pay over to t̂he sum of dollars

(Name of Funeral Home)

($ ) which payment shall constitute a release and certificate by me for such assigned and paid

proceeds.

(Signed Beneficiary)

STATE OF , COUNTY.

Dated:

Notary Public:

fax: 508-473-0726 www.bumafuneralhome.com