Pursuant to a Pet Cryonic Storage Agreement dated ____________ between the Cryonics

Institute and __________________________________________ (the Member), the Member hereby designates as successor the person(s) identified below, subject to the terms of the aforesaid Pet Cryonic Storage Agreement.

If more than one person is designated, CI will recognize the first named as the successor, after the death of the Member; or if the first named for any reason is not available, CI may at its discretion recognize the second named, or the third.

It is permissible to designate a successor by category rather than by name—for example, “my eldest surviving descendant.” In such case, however, CI will not be accountable or liable for any error in identifying such successor.

Designate(s) (in order of priority, if more than one):

(Please print or type name or category for each; and if name, address and social security number.)

Signed and dated by Member:

_________________________________________________  ________________

Signature                                                                                             date