THE TRANSPLANTATION OF HUMAN ORGANS RULES, 1995 (GSR NO. 51(E), dr. 4-2-1995) [As amended vide GSR 571(E), dt.31-7-2008]

FORM - 6
[(See rule 4(2) (b)]  

I................................... s/o,d/o,w/o ....................... 
aged ...................resident of. ..............................
having lawful possession of the dead body Sri/Smt/km .....................s/o,d/o,w/o ..................................
aged...........  of..................................................... having  known that the deceased has not expressed any objection to his/her organ/organs being removed for therapeutic purposes after his/her death and also having reasons to believe that no near relative  of the said deceased person has objection to any of his/her organs 
being used for therapeutic purposes authorise removal of his/her body organs, 

Signature.....................
name. .......................
Dated..........................                         
Place …………………. ......... 
Person in lawful possession of the dead body 
  Address..................................................................
..............................................................................