This is a Certificate of Religious Belief and Religious Objection to Autopsy of __________________________________________,

currently residing at _______________________________________________________

_______________________________________________________________________.

I, __________________________________________, do hereby declare that I hold autopsy of my body and mutilation of my brain to be a violation of my religious beliefs and of my religious rights. Based on my religious beliefs, I do not wish to be autopsied under any circumstances.

In witness thereof, _________________________________________________ signs, publishes, and certifies the above to be his/her wish concerning the disposition of his/her remains, this __________ day of _________________________, ________________.

Signature of Certifier ________________________________________________________

Witness 1 Signature __________________________________________Date ____________

Printed Name _______________________________________________________________

Address ___________________________________________________________________

Witness 2 Signature __________________________________________Date ____________

Printed Name _______________________________________________________________

Address ___________________________________________________________________