The Transplantation of Human Organs Rules, 1995 - Form 5

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............................