FORM 9
[Refer rule 4(3) (a) (b)]
I, Shri/Smt. …………………………s / o. w / o, Shri …………………… resident of ……… hereby authorize removal of the organ / organs, namely, ……………………... for therapeutic purpose from the dead body of my son / daughter Shri / Km. ………………………...aged …………………… Whose brain-stem death has been duly certified in accordance with the law.
Signature ……………………….
Name ………………………….
Place ……………………
Date …………………….
To be self attested across the affixed photograph