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: ________________________