Statement: Certificate of Religious Belief (L. Ron Hubbard) (January 20, 1986)

CERTIFICATE OF RELIGIOUS BELIEF ¹

(GOVERNMENT CODE SS27491.43)

I, LAFAYETTE RONALD HUBBARD, declare:

1) I am a resident of the state of California and over eighteen (18) years of age.

2) Based upon my religious beliefs, I object to any and all post mortem anatomical dissections or other autopsy procedures being conducted on my body. Such autopsy procedures would violate my religious convictions.

IN WITNESS WHEREOF, I have executed this Certificate of [Relig]ious Belief this 20 day of Jan, 1986.

[signed and overlaid with fingerprints]

WITNESSES

We declare under penalty of Perjury that the foregoing is [true] and correct.

[N]ame: PATRICK D. BROEKER
(print)

[Re]sidential address: STAR ROUTE CRESTON
CRESTON, CA 93432

[S]ignature: [signed Patrick D. Broeker]

[Cert]ificate of Religious Belief p.2

[N]ame: ANNE M. BROEKER
(print)
[R]esidential address: STAR ROUTE CRESTON
CRESTON, CA 93432

[S]ignature: [signed Anne M. Broeker]

[N]ame: Stephen J. PFAUTH
(print)

[R]esidential address: Star Route Creston
Creston, CA
93432

[S]ignature: [signed Stephen J. Pfauth]

[signed and overlaid with fingerprint L. Ron Hubbard]

Notes