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Anatomical Gift


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.

I give:

(__) 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

institution ________________________________________________;

(__) the following individual for treatment _______________________;

for the following purposes:

(__) any purpose authorized by law;

(__) transplantation;

(__) therapy;

(__) research;

(__) 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:


Witness: ______________________________________________________________________

Witness: ______________________________________________________________________

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