I, insert your name*, represent that I am authorized to sign this General Release & Authorization on behalf of the deceased, insert name of decedent*. I hereby authorize New York Blood Center, Inc., d/b/a New York Blood Center Enterprises (“NYBCe”*) to publish the Decedent’s photograph, videotape or recorded image for publicity or public affairs purposes (collectively “Photograph”), along with Decedent’s name, in any NYBCe publication selected by NYBCe, including publication on NYBCe’s website. I understand and accept that Decedent’s Photograph will become and remain the property of NYBCe and that NYBCe may reproduce and make it available for publication along with Decedent’s name in news, promotional or other similar media (including Internet or other on-line media) with the purpose of advancing NYBCe’s mission. I also understand and accept that I shall have no right to inspect or approve Decedent’s Photograph or use of Decedent’s Photograph and name by or on behalf of NYBCe, nor will I receive any compensation for use of Decedent’s Photograph and name.

With regard to all current and future publications in which NYBCe may use Decedent’s name and Photograph, I understand and accept that this authorization will remain in effect unless and until I contact NYBCe in writing to revoke this authorization.

Because NYBCe puts a lot of time, energy, and resources into conceiving and developing the work product for its publicity and public affairs activities, NYBC asks that you notify the following department in writing as soon as possible if you decide to revoke your authorization:

NYBCe Corporate Communications
310 E. 67th Street
New York, NY 10065
(212) 570-3220

* NYBCe is comprised of five operating divisions: New York Blood Center, Rhode Island Blood Center, Blood Bank of Delmarva, Innovative Blood Resources (Memorial Blood Centers and Nebraska Community Blood Bank), and Community Blood Center of Greater Kansas City