[Refer rule 4(2) (b)]
. s / o, w / o, d / o Shri
.having lawful possession of the dead body of Shri/Smt./Km.
.s / o, w / o, d / o Shri
.. residen of
having known that the deceased has not expressed any objection to his / her organ / organs being removed for therapeutic pur-poses after his / her death and also having reasons to believe that no near relative of the said deceased person has objection to any of his / her organs being used for therapeutic purposes, authorize removal of his / her body organs, namely,
Person in lawful possession of the dead body