[Refer rule 4(2) (b)]
I, ………….…. s / o, w / o, d / o Shri ………………………aged……………… resident of ……………….having lawful possession of the dead body of Shri/Smt./Km. ……………………………………………………….s / o, w / o, d / o Shri ……………… aged ……………….. 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, ………………….
Signature
Date ……………………
Place ……………………
Person in lawful possession of the dead body
Address …………………………………
…………………………………
