I, ____________________________________________________________________,
(Your name and address)
consent to the use of assisted reproduction to conceive a child or children of mine after my death. I understand that, unless I revoke this consent and authorization in a written document signed by me in the presence of two witnesses who also sign the document, this consent and authorization will remain in effect for seven years from this day and that I cannot revoke or modify this consent and designation by any provision in my will.
Signed this day of ,
_____________________________________________
(Your signature)
Statement of witnesses:
I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting willingly and free from duress. He or she signed this document in my presence. I am not the person authorized in this document to control the use of the genetic material of the person who signed this document.
Witness:
Address:
Date:
Witness:
Address:
Date:
I, ____________________________________________________________________,
(Your name and address)
consent to the use of my (sperm or ova) (referred to below as my "genetic material") to conceive a child or children of mine after my death, and I authorize
________________________________________________________________________
(Name and address of person)
to decide whether and how my genetic material is to be used to conceive a child or children of mine after my death.
In the event that the person authorized above dies before me or is unable to exercise the authority granted I designate
________________________________________________________________________
(Name and address of person)
to decide whether and how my genetic material is to be used to conceive a child or children of mine after my death.
I understand that, unless I revoke this consent and authorization in a written document signed by me in the presence of two witnesses who also sign the document, this consent and authorization will remain in effect for seven years from this day and that I cannot revoke or modify this consent and designation by any provision in my will.
Signed this day of,
_____________________________________________
(Your signature)
Statement of witnesses:
I declare that the person who signed this document is personally known to me and appears to be of sound mind and acting willingly and free from duress. He or she signed this document in my presence. I am not the person authorized in this document to control the use of the genetic material of the person who signed this document.
Witness:
Address:
Date:
Witness:
Address:
Date:
N.Y. EPTL 4-1.3