Amendment status not verified — confirm the current text below against the official source.
I hereby authorise / do not authorize removal of his/her body organ(s) and/or tissue(s), namely (A n y o r g a n a n d tis s u e / K id n e y /L iv e r /H e a r t /L u n g s /I n te s tin e /C o r n e a /S k in /B o n e /H e a r t V a lv e s /A n y o th e r ; p le a s e s p e c ify ) .....................................................................for therapeutic purposes. I also give permission for drawing of a blood sample for serology testing and am w illing to share social/behavioural and medical history to facilitate proper screening of the donor for safe transplantation of the organs/ tissues. Date.............................. Signature of near relative /person in lawful possession of the dead body, and address for correspondence*. Place............................... Telephone No.....................E m ail:................................. * in case of the minor the declaration shall be signed by one of the parent of the minor or any near relative authorised by the parent. In case the near relative or person in lawful possession of the body refuses to sign this form, the same shall be recorded in writing by the Registered Medical Practitioner on this Form. (Signature of Witness 1) 1.Shri/Smt./Km....................................................................S/o,D/o,W/o................................................................................ aged......................... resident of.............................................................................Telephone No..................................................E m ail:........................................................ (Signature of Witness 2) 2.Shri/Smt./Km....................................................................S/o,D/o,W/o................................................................................ aged......................... resident o f......................................... Telephone No........................................ Email:................................ F O R M 9 For unclaimed body in a hospital or prison (T o b e c o m p le te d b y p e r s o n in la w fu l p o s s e s s io n o f th e u n c la im e d b o d y ) I .......... Is e e r u le 5 ( 1 ) ( b ) l .................S/o,D/o,W/o....................... aged.................. ..resident of ...................... having lawful possession of the dead body of Shri/Smt./Km S/o,D/o,W/o..... ........................... a g e d ....................... resident of ..a n d having known that no person has come forward to claim the body of the deceased after 48 hours of death and there being no reason to believe that any person is likely to come to claim the body I hereby, authorise removal of his/her body organ(s) and/or tissue(s), namely.....................................................................for therapeutic purposes. body I hereby, authorise removal of his/her body organ(s) and/or tissue(s), namely.....................................................................for therapeutic purposes. [HTX I I - [ F M 3 ( i) ] HTTT d T TTtdT : V lT / T T 59 Signature, Name, designation and Stamp of person in lawful possession of the dead body. Dated..................Place.................... Address for correspondence...................................................................... Telephone No........................................ (Signature of Witness 1) 1 .Shri/Smt./Km................................................................... S/o,D/o,W/o............ aged......................... resident of.................................................................... No..................................................E m ail...................................................... (Signature of Witness 2) 2.Shri/Smt./Km................................................................... S/o,D/o,W/o............ aged......................... resident o f......................................... Telephone No. .Email Telephone Email FORM 10 _For certification of brain stem death (T o b e f i l l e d b y th e b o a r d o f m e d ic a l e x p e r ts c e r tify in g b r a in -s te m d e a th ) [See rules 5(4)(c) and 5(4)(d)] We, the following members of the Board of medical experts after careful personal examination hereby certify that Shri/Smt./Km.................................................................................... aged about................................_son of /wife of / daughter o f.................................................................Resident of is dead on account of permanent and irreversible cessation of all functions of the brain-stem. The tests carried out by us and the findings therein are recorded in the brain-stem death Certificate annexed hereto. Dated........................ Signature................................................