The Cryonics Institute, located at 24355 Sorrentino Court, Clinton Township, MI 48035, has received the person named _____________________________________________ (referred to below as "the SA-CI Standby Recipient") who was pronounced legally dead on _________________________________ (date)
and has been transported to The Cryonics Institute with assistance from representatives of Suspended Animation, Inc.
The Cryonics Institute acknowledges that it has received the SA-CI Standby-Transport Recipient and is assuming all responsibility for The SA-CI Standby-Transport Recipient as of the time and date stated below. The Cryonics Institute agrees that Suspended Animation has no further responsibility toward the SA-CI Standby-Transport Recipient, relatives and friends of the SA-CI Standby-Transport Recipient, or others with an interest in the disposition of the SA-CI Standby-Transport Recipient, subsequent to the time and date stated below.
Signed Date and Time (Eastern Standard Time)
_________________________________ _________________________________
for The Cryonics Institute
Witnessed Date and Time (Eastern Standard Time)
_________________________________ __________________________________
For definitions of capitalized terms in this text, please see the documents titled "Individual Agreement Regarding Standby-Transport for a Cryonics Institute Member by Suspended Animation" or "Cryopreservation Agreement between the Cryonics Institute and Suspended Animation."