NEW YORK CERTIFICATE OF RELIGIOUS BELIEF

Pursuant to New York Public Health Law Section 4210-c(1), I hereby execute this Certificate of Religious Belief: Any autopsy of my body is a violation of my religious beliefs. Any procedure which allows the post-mortem deterioration of my body is a violation of my religious beliefs. Further it is my wish and directive that my remains be placed into cryopreservation as soon as possible following my death.

Dated: ___________________________________

Signed: __________________________________

Printed Name: _____________________________

Witnessed:

Dated: ____________________________________

Signed: ____________________________________

Printed Name: ______________________________

Address: __________________________________

Witnessed:

Dated: ____________________________________

Signed: ____________________________________

Printed Name: ______________________________

Address: __________________________________