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The Transplantation of Human Organs Rules, 1995

FORM -5
[(See rule 4(2) (a)]

I .................................................................. S/o, D/o, W/o ...................... ............. ............ aged ...................................... resident of ................. in the presence of persons mentioned below hereby unequivocally authorise the removal of my organ/organs, namely, ................................ from my body after my death for therapeutic purposes.


Dated: Signature of the Donor

(Signature)

1. Shri/Smt./Km............................................................................

S/o, D/o, W/o .......................................................................... aged ....................resident of .............................. .................. .........................

(Signature)

2. Shri/Smt./Km................................................................of ....................aged ............................... resident of ............................................ is a near relative to the donor as................................................................

Dated............................

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