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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 ___________________________________________________________________