Organ Donation form

I, _____________, of ________________, give my organs, tissues, or parts as directed below. This Anatomical Gift will take effect upon my death.

I give: (initial one of the three options)

______ any needed organs, tissues, or parts.

______ any needed organs, tissues, or parts except:

______ the following organs, tissues, or parts only:

I give my organs, tissues, or parts indicated above to be used for: (initial one of the two options)

______ any purpose authorized by law.

______ the following purposes only: (initial all that apply)

______ transplantation

______ research

______ therapy

______ education

Limitations or special wishes, if any: None.

If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.

Date Signed: _________.

Donor

Signature:

Donor's Date of Birth:

I witnessed that this document was signed in my presence by the Donor. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:

Witness __________________________________

Signature: _______________________________

Witness __________________________________

Signature: _______________________________