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Consent Release

CONSENT/RELEASE FOR CRYOPRESERVATION

WHEREAS, ____________________________________, my _____________________ being of sound mind, has expressed his/her desire to have his/her body preserved at death by the process of cryonics, and has contracted with the Cryonics Institute (a Michigan nonprofit corporation) whose address is 24355 Sorrentino Court, Clinton Township, MI 48035, to do so;

WHEREAS, I may be authorized or obligated to dispose of his/her body upon his/her death, and am willing to accede to his/her wishes regarding such disposal;

I HEREBY AUTHORIZE AND DIRECT that immediately after his/her legal death, his/her body shall be delivered to the Cryonics Institute for purposes of cryopreservation, and that no substitute or alternative donations be made.

IN WITNESS WHEREOF, the parties have signed this Agreement, which is finally executed at

Clinton Township, Michigan.

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 ___________________________________________________________________


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