[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, .
Person in lawful possession of the dead body