Anatomical Gift (Organ Donation) Agreement by Living Donor

for Your State

This kit provides tools and guidelines to assist you in creating your Anatomical Gift.

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No one likes considering their own death, but by avoiding the subject, it is likely that many of your wishes regarding the disposition of your body will be ignored. By preparing a written Anatomical Gift, you can rest assured that your desire to donate your organs will be carried out.

This kit provides tools and guidelines to assist you in creating your Anatomical Gift and is designed to fulfill the obligations of the Uniform Anatomical Gift Act.

This attorney-prepared packet contains:
  1. General Instructions for preparing your Anatomical Gift
  2. Anatomical Gift Form
State Law Compliance: Designed for use in all states
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.
 
 
Donation Pursuant to the Uniform Anatomical Gift Act
(By Living Donor)

 

 

Upon my death, I ____________________________________ (the “Donor”), hereby (mark applicable box):
  
o  Give any needed organs, tissues, or parts, OR
  
o  Give the following organs, tissues, or parts only: ____________________________
 
________________________________________________________________________
 
________________________________________________________________________
 
________________________________________________________________________
 
 
My gift is for the following purposes (strike any of the following you do not want):
          (1) Transplant
          (2) Therapy
          (3) Research
          (4) Education
 
 
 
(Optional) I designate ___________________________________ as my particular physician or surgeon to carry out the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authorize any physician, surgeon, technician, or enucleator to carry out the appropriate procedures.
 
 
 
SIGNATURE:  (Sign and date the form here:)
 
Date: __________________
 
Sign your name:  ______________________________________
 
Print your name:  ______________________________________
 
Address:   ____________________________________________
City:   _______________________________________________
State:  _______________________________________________WITNESS FORM
 
[An anatomical gift may be made only by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual and by two witnesses, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed.]
 
 
Witness Statement:  We have signed at the direction and in the presence of the Donor and each other.  The individual signing the Donation of Gift was directed to do so by the Donor and signed the document in his/her presence as well as ours.  
 
 
FIRST WITNESS:
Date: __________________
 
Signature: ___________________________________________
 
Name: _______________________________________________
Address:   ____________________________________________
City:   _______________________________________________
State:  _______________________________________________
 
 
SECOND WITNESS:
Date: __________________
 
Signature: ___________________________________________
 
Name: _______________________________________________
Address:   ____________________________________________
City:   _______________________________________________
State:  _______________________________________________
 
Number of Pages4
DimensionsDesigned for Letter Size (8.5" x 11")
EditableYes (.doc, .wpd and .rtf)
UsageUnlimited number of prints
Product number#28156
This is the content of the form and is provided for your convenience. It is not necessarily what the actual form looks like and does not include the information, instructions and other materials that come with the form you would purchase. An actual sample can also be viewed by clicking on the "Sample Form" near the top left of this page.
 
 
Donation Pursuant to the Uniform Anatomical Gift Act
(By Living Donor)

 

 

Upon my death, I ____________________________________ (the “Donor”), hereby (mark applicable box):
  
o  Give any needed organs, tissues, or parts, OR
  
o  Give the following organs, tissues, or parts only: ____________________________
 
________________________________________________________________________
 
________________________________________________________________________
 
________________________________________________________________________
 
 
My gift is for the following purposes (strike any of the following you do not want):
          (1) Transplant
          (2) Therapy
          (3) Research
          (4) Education
 
 
 
(Optional) I designate ___________________________________ as my particular physician or surgeon to carry out the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authorize any physician, surgeon, technician, or enucleator to carry out the appropriate procedures.
 
 
 
SIGNATURE:  (Sign and date the form here:)
 
Date: __________________
 
Sign your name:  ______________________________________
 
Print your name:  ______________________________________
 
Address:   ____________________________________________
City:   _______________________________________________
State:  _______________________________________________WITNESS FORM
 
[An anatomical gift may be made only by a document of gift signed by the donor. If the donor cannot sign, the document of gift must be signed by another individual and by two witnesses, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been so signed.]
 
 
Witness Statement:  We have signed at the direction and in the presence of the Donor and each other.  The individual signing the Donation of Gift was directed to do so by the Donor and signed the document in his/her presence as well as ours.  
 
 
FIRST WITNESS:
Date: __________________
 
Signature: ___________________________________________
 
Name: _______________________________________________
Address:   ____________________________________________
City:   _______________________________________________
State:  _______________________________________________
 
 
SECOND WITNESS:
Date: __________________
 
Signature: ___________________________________________
 
Name: _______________________________________________
Address:   ____________________________________________
City:   _______________________________________________
State:  _______________________________________________
 

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