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Alaska ________________________ Serial Number, if any: ____________________________________ 3 _______________________________ (name of person who acknowledged). ______________________________________________________ Signature of Person Taking Acknowledgement Title or Rank ___________________________________________ ) ) Judicial District _________________________ ) 2 ACKNOWLEDGEMENT FORM The foregoing instrument was acknowledged before me this ___________________ (date) by ________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ State of _______he person qualified to take acknowledgements. WITNESS FORM _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: __________________ence of two persons or a person who is qualified to take acknowledgments under AS 09.63.010 . The witness form below may be used for the two witnesses. The acknowledgement form below may be used for t_ Place: _______________________________________________________ If another person is to sign for the declarant at the declarant's direction, the person signing for the declarant must sign in the pres_____________________________________________________________________ Signed on: __________________________________________________ (date) Signature ___________________________________________________: Eyes Bone and connective tissue Skin Heart Other: Limitations: Organ: Heart Kidney(s) Liver 1 Lung(s) Pancreas Other: ______________________________________________________________________ _______an can be evaluated to determine if the organ is suitable for donation. OPTIONAL: In the event of my death, I donate the following part(s) of my body for the purposes identified in AS 13.50.020 Tissuedeclaration or by another method, and if I am in a hospital when a do not resuscitate order is to be implemented for me, I do not want the do not resuscitate order to take effect until the donated orgthat nutrition or hydration (food and water) be provided by gastric tube or intravenously if necessary. Notwithstanding the other provisions of this declaration, if I have donated an organ under this tment, I direct my attending physician to: withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain. I [__] do [__] do not desire t time, it is my desire that my life not be prolonged by administration of life-sustaining procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treabject to the Disclaimers and Terms of Use found at findlegalforms.com Living Will DECLARATION If I should have an incurable or irreversible condition that will cause my death within a relatively shormmended when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is suhould only be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms sapy or transplantation needed by the individual. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpoce, or therapy; (3) a bank or storage facility, for medical or dental education, research, advancement of medical or dental science, therapy, or transplantation; or (4) a specified individual for theradvancement of medical or dental science, therapy, or transplantation; (2) an accredited medical or dental school, college or university for education, research, advancement of medical or dental scienowing persons may become donees of gifts of a decedent's body or a part of a decedent's body for the purposes stated: (1) a hospital, surgeon, or physician, for medical or dental education, research, nding physician or health care provider shall make the revocation a part of the declarant's medical record. AS 13.50.020. Potential Donees and Purposes For Which Anatomical Gifts May Be Made. The follof that physician upon communication to the physician or health care provider by the declarant or by another to whom the revocation was communicated. Information & Instructions ­ Page 2 (b) The atte to communicate an intent to revoke, without regard to mental or physical condition. A revocation is only effective as to the attending physician or any health care provider acting under the guidance valid. AS 18.12.020. Revocation of Declaration. (a) Except as provided in AS 13.50.050 for an anatomical gift, a declaration may be revoked at any time and in any manner by which the declarant is ableomplies with this chapter, that an anatomical gift in the declaration complies with this chapter and AS 13.50, and that the declaration, including any anatomical gift contained in the declaration, is A declaration may, but need not, be in the following form: (see form below) (d) A physician or health care provider may presume, in the absence of actual notice to the contrary, that the declaration c copy of the declaration to the declarant's physician. A physician or other health care provider who is provided a copy of the declaration shall make it a part of the declarant's medical records. (c) rge a fee for preparing a declaration. (b) Except as provided under AS 13.50.014 - 13.50.016 for an anatomical gift contained in the declaration, it is the responsibility of the declarant to provide aned by another person at the declarant's direction, the signer shall sign in the presence of two persons or a person who is qualified to take acknowledgements under AS 09.63.010 . A person may not chacontains an anatomical gift under AS 13.50, the gift takes effect upon the death of the person. The declaration shall be signed by the declarant, or another person at the declarant's direction. If sigon. The declaration is given operative effect only if the declarant's condition is determined to be terminal and the declarant is not able to make treatment decisions, except that, if the declaration Life-Sustaining Procedures. (a) A competent person who is at least 18 years old may execute a declaration at any time directing that life-sustaining procedures be withheld or withdrawn from that perser 12 Section 10 et. Seq. of the Alaska Statutes. For your convenience, we have included useful excerpts from the Alaska Statutes relating to Living Wills. AS 18.12.010. Declaration Relating to Use ofInformation and Instructions Alaska Living Will This package contains (1) Information and Instruction for Alaska Living Will; (2) Alaska Living Will. This Alaska Living Will is based on Title 18 Chapt Alaska