CALIFORNIA CERTIFICATE OF RELIGIOUS BELIEF

Pursuant to Section 27491.43 of the Government Code of the State
of California, I hereby execute this Certificate of Religious Belief:

Any autopsy of my body is a violation of my religious beliefs.
Any procedure which allows the post-mortem deterioration
of my body is a violation of my religious beliefs. Further, it is
my wish and directive that my remains be placed into
cryopreservation as soon as possible following my death.

Dated: ___________________________________

Signed: __________________________________

Printed Name: _____________________________

Witnessed:

Dated: ____________________________________

Signed: ____________________________________

Printed Name: ______________________________

Address: __________________________________

Witnessed:

Dated: ____________________________________

Signed: ____________________________________

Printed Name: ______________________________

Address: __________________________________