UNIFORM ANATOMICAL GIFT ACT DONATION
I am of sound mind and 18 years or more of age. I hereby make this anatomical gift to take effect upon my death. The marks in the appropriate squares and words filled into the blanks below indicate my desires.
(__) my body;
(__) any needed organs or parts;
(__) the following organs or parts
To the following person or institutions
(__) the physician in attendance at my death;
(__) the hospital in which I die;
(__)the following named physician, hospital, storage bank or other medical
(__) the following individual for treatment _______________________;
for the following purposes:
(__) any purpose authorized by law;
(__) medical education.
Dated ______________ City and State _________________________
Signed by the Donor in the presence of the following who sign as witnesses.
Signature of Donor: _________________________________________________________
Address of Donor:
State Specific Power of Attorney Forms
—-For State Specific Power of Attorney Forms you can download in Word Format go to