AUTHORIZATION OF ANATOMICAL DONATION CRYOCARE FOUNDATION 1013 Centre Road Suite 301 Wilmington, Delaware 19805-1297 <<< When signing up with CryoCare, please use the hardcopy paperwork >>> <<< provided by CryoCare rather than your own printout of this file. >>> 1. I, ________________________________________________, now residing at ________________________________________________________________________ declare that I am _____ years of age, of sound mind and memory, and that it is my wish that upon my death, my human remains be preserved by the treatment known as cryopreservation. 2. For this purpose, and in accordance with the laws governing anatomical donations, I hereby direct that upon my legal death my human remains be delivered to the CryoCare Foundation (CryoCare), a Delaware Corporation, having its principal office and place of business at 1013 Centre Road, Suite 301, Wilmington, Delaware 19805-1297, or to its agents or representatives, at such place as they may direct. 3. I further direct that, when and where possible, such delivery shall take place immediately after my legal death, without embalming or autopsy. 4. I further declare that I have not received any remuneration whatsoever in connection with this donation of my human remains, and that I have made this donation for the purpose of furthering cryobiological and human cryopreservation research. 5. I understand that this action gives CryoCare full and complete control of my human remains. 6. I understand that human cryopreservation is not consistent with contemporary medical or mortuary practice. As stated in the other forms which I have executed with CryoCare, I understand that there are no guarantees or any known probability that the procedure of human cryopreservation will be successful. 7. If a legal challenge is raised to this Authorization of Anatomical Donation, I authorize CryoCare to take custody of, and have full and complete control over, my human remains by whatever legal means may be available for the purpose of cryopreserving them. If a legal challenge to this procedure is raised by any institution, individual(s), or government agency, I authorize CryoCare to use monies from my Cryopreservation Funding to pay for the legal expenses involved in defending its authority and ability to cryopreserve my human remains. 8. In witness thereof, I hereby sign, publish, and declare the above, in conjunction with my Cryopreservation Agreement and my Consent for Cryopreservation to be my last wish and instruction concerning the disposal of my human remains following my legal death. _________________________ ______________________________ Signature of Donor Responsible person if Donor is unable to sign or is an unemancipated minor or otherwise incompetent. _________________________ Date __________________(a.m./p.m.) ______________________________ Time Relationship to Client WITNESSES' SIGNATURES Two (2) witnesses are required to sign in the presence of each other and the Donor. At the time of signing, witnesses must not be relatives of the Donor, health care providers of any kind, or officers, directors, or agents of CryoCare. YOUR SIGNATURE AS A WITNESS CONFIRMS YOUR ACKNOWLEDGEMENT THAT: 1. You have witnessed the signature of the Donor on this document. 2. The Donor has represented to you that s/he understands and agrees to the purposes and terms of this document. 3. The Donor has declared to you that the arrangement described herein, in conjunction with his/her Cryopreservation Agreement and Consent for Cryopreservation constitutes his/her last wish as to the disposition of his/her human remains after legal death. WITNESSED THIS _______ DAY OF _____________________, 19__________ TIME ______________(a.m./p.m.) 1. Signature ____________________________________________ Printed ____________________________________________ Address ____________________________________________ ____________________________________________ 2. Signature ____________________________________________ Printed ____________________________________________ Address ____________________________________________ ____________________________________________