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By my signature below I affirm the following:

(1) I am the child of __________________________________________________________________________[name of parent]

(2) _______________________________________________________________________________________[name of parent]
has no living spouse to whom he/she was legally married at the time of his/her legal death

(3) _______________________________________________________________________________________[name of parent]
has no living children other than those who have signed this document

(4) I give permission for my parent ______________________________________________________________[name of parent]
to have cryonic preservation as a means of disposition of his/her human remains.

_________________________________________________________________________________________[printed name of child 1]

_________________________________________________________________________________________[printed address of child 1]

______________________________________________________________________[signature of child 1]   Date ____________

_________________________________________________________________________________________[printed name of child 2]

_________________________________________________________________________________________[printed address of child 2]

______________________________________________________________________[signature of child 2]   Date ____________

_________________________________________________________________________________________[printed name of child 3]

_________________________________________________________________________________________[printed address of child 3]

______________________________________________________________________[signature of child 3]   Date ____________

Subscribed and sworn to before me this _______ day of ____________________________________________________

Signature of Notary Public or Lawyer _____________________________________________________________________

Name of Notary or Lawyer ________________________________________ State or Country _______________________