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/— GANADARPAN \
sprt.— 4,0: KHAN ROAD (2nd Flor)
KOLKATA. 700.025
Phone : (033) 2454-0891
e-mail : ganadarpan@gmail.com
Webste : www.ganadarpaninciain
a SUDIPTA SAHA ROy-9830061710
NOTTO sera co tee Te
12 Waar saws suerets
tot Organ sue Tai Opie ‘SWAPAN KUMAR BANDHU-7003554462
Dy cssssceesssseee
S/0, D/O, W/O
aged years and date of birth Gender.
Resident of socceennnnnnnnne sssnennnnnee
PO - cccccceeeeeeeeeeeeeeeees PS = escccsessesneecessnnneeePIN
by profession being sound mind and judgement in the presence of persons
(Witnesses) mentioned below (with their signature) hereby unequivocally authorise the
removal of organ(s) and tissue(s) [Heart, Lungs, Kidneys, Liver, Pancreas, Comeas, Skin,
Bone, Heart Valves, Blood Vessels) from my body after being declared Brain stem dead by the
board of medical experts and consent to donate the same for therapeutic purpose and also donate
my dead body in case of Cardio Repertory failure death for academic and research purpose and
potential tissue(s) for therapeutic purpose.
1 further declare that this pledge has been made with full consciousness and not under form of
duress or coercion,
If there is any change in name, address or phone no the same will be communicated to
GANADARPAN.
My Blood Group
T put my hand this c Two thousand
Signature tn full
Witness to the Signature Address :
with relation address & Phone no. Present
»
Permanent
2» Ph. No,
\ E-mail
Genera Secretary
In association with :
