Alcor: Declaration of Intent to be Cryopreserved

DECLARATION OF INTENT TO BE CRYOPRESERVED

I hereby declare that it is my wish that upon my legal death, my remains be preserved cryogenically or cryopreserved, and my preserved remains be stored with the hope of eventual resuscitation. This declaration supersedes and revokes any contrary provisions or arrangements, express or implied, heretofore made by me, regarding disposition of my remains upon or following my legal death. This instrument does not, however, constitute a contract with any organization or other party for the cryopreservation of my remains.

(Signed): __________________________________________________________

(Printed Name:) _____________________________________________________

(Address:) _________________________________________________________

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(Date:)___________________________________________

Witness (Signature:) __________________________________________________

(Printed Name:) _____________________________________________________

(Address:) _________________________________________________________

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Witness (Signature:) _________________________________________________

(Printed Name:) _____________________________________________________

(Address:) _________________________________________________________