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This Rider is attached to the Cryonic Suspension Agreement between ______________________________ currently residing at
____________________________________________________________ (hereinafter referred to as the "Patient") and the CRYONICS INSTITUTE, a Michigan nonprofit corporation (hereinafter "CI"), which agreement was finally executed at Clinton Township, Michigan.
In the event that CI does not commence or does not continue the Patient's cryopreservation, pursuant to the provisions of this Agreement, and CI possesses or receives part or all of the Cryopreservation Fee through payment under the Patient's life insurance policy, trust agreement, or otherwise, any portion of the Cryopreservation Fee to which CI is not entitled shall be distributed as specified and initialed below [choose ONLY ONE of (1) to (4) by initialing your choice]
(1) ______ (initials) I, the Patient, give the Cryopreservation Fee funds as a donation to CI
If choosing this option, you may want to be more specific about how CI is to
use the funds.
(If so, initial one ONLY)
_____ Research ______ Prepayment for needy CI Members _____Where most needed
(2) ______ (initials) I, the Patient, give the Cryopreservation Fee funds as
a prepayment for
cryopreservation at the Cryonics Institute for the following person:
Name _________________________________________________________________
Address __________________________________________________________________
_________________________________________________________________________
Relation to Patient ________________________________________________________
OR
(3) ______ (initials) I, the Patient, give the Cryopreservation Fee funds to the following person
Name _________________________________________________________________
Address __________________________________________________________________
_________________________________________________________________________
Relation to Patient ________________________________________________________
OR
(4) ______ (initials) I, the Patient, give the Cryopreservation Fee funds to
my estate, to be distributed in
accordance with the provisions of my last will and testament.
IN WITNESS WHEREOF, the parties have signed this Agreement, which is finally executed at
Clinton Township, Michigan.
CRYONICS INSTITUTE: by _________________________________________________
It's Contract Officer, dated ___________________
PATIENT (CI MEMBER) _______________________________, dated ______________
Subscribed and sworn to before me this _____ day of ________________________________
Signature of Notary Public _____________________________________________________
Name of Notary ________________________ County and State _______________________
If two witnesses are used instead of a notary, for each witness please show signature, printed name, address, and date:
Witness 1 Signature __________________________________________Date ____________
Printed Name _______________________________________________________________
Address ___________________________________________________________________
Witness 2 Signature __________________________________________Date ____________
Printed Name _______________________________________________________________
Address ___________________________________________________________________