[Refer rule 4(2) (b)]
having lawful possession of the dead body of Shri/Smt./Km.
s/o, w/o, d/o Shri
after having known that no objection was expressed by the deceased to any of his human organ being used after his death for therapeutic purposes and also having reason to believe that no near relative of the deceased person has objection to any of the deceased persons organ being used for therapeutic purposes, hereby authorize the removal of the deceaseds organ, namely,
. for therapeutic purposes.
Time and date