I hereby declare that it is my wish that upon my legal death, my remains be preserved
cryogenically or cryopreserved, and my preserved remains be stored with the hope
of eventual resuscitation. This declaration supersedes and revokes any contrary
provisions or arrangements, express or implied, heretofore made by me, regarding
disposition of my remains upon or following my legal death. This instrument does
not, however, constitute a contract with any organization or other party for the
cryopreservation of my remains.
(Signed): __________________________________________________________
(Printed Name:) _____________________________________________________
(Address:) _________________________________________________________
_________________________________________________________________
(Date:)___________________________________________
Witness (Signature:) __________________________________________________
(Printed Name:) _____________________________________________________
(Address:) _________________________________________________________
_________________________________________________________________
Witness (Signature:) _________________________________________________
(Printed Name:) _____________________________________________________
(Address:) _________________________________________________________
_________________________________________________________________
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