This Rider is attached to the Cryonic Suspension Agreement between
______________________________________________________________________________
currently residing at _____________________________________________________________
(hereinafter referred to as the "Patient") and the CRYONICS INSTITUTE, a Michigan nonprofit corporation (hereinafter "CI").
PATIENT (CI MEMBER) _______________________________, dated ______________
Subscribed and sworn to before me this _____ day of ________________________________
Signature of Notary Public _____________________________________________________
Name of Notary ________________________ County and State _______________________
If two witnesses are used instead of a notary, for each witness please show signature, printed name, address, and date:
Witness 1 Signature __________________________________________Date ____________
Printed Name _______________________________________________________________
Address ___________________________________________________________________
Witness 2 Signature __________________________________________Date ____________
Printed Name _______________________________________________________________
Address ___________________________________________________________________
IN WITNESS WHEREOF, the parties have signed this Agreement, which is finally executed at Clinton Township, Michigan.
CRYONICS INSTITUTE: by _________________________________________________
It's Contract Officer, dated ___________________