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Uniform Donor Form

This is the Uniform Donor Form of __________________________________________,

currently residing at _______________________________________________________


In the hope that I may help others, I hereby make this anatomical gift, to take effect upon my death. The words below indicate my desire.

I intend that my remains be preserved cryogenically. For this purpose I authorize delivery of my remains to the CRYONICS INSTITUTE, 24355 Sorrentino Court, Clinton Township, Michigan 48035, its agents or representatives, at such place as they may direct, pursuant to the Uniform Anatomical Gift Act.

I direct that such delivery take place as soon as possible after my death, without embalming or autopsy.

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

Signature of Donor ________________________________________________________

Date of Birth of Donor _____________________________________________________

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 ___________________

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 ___________________________________________________________________