OHIO CERTIFICATE OF RELIGIOUS BELIEF

Pursuant to Ohio Code 313.131, I hereby execute this
Certificate of Religious Belief: Ay 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: ________________________