Organ Donor Declaration for:[donor name]

According to the guidelines of the Uniform Anatomical Gift Act, I choose, upon my death, to donate:

     I give:
     [  ]  a) Any needed organs,
     [  ]  b) Only the following organs for purposes of transplantation,
              therapy, education or medical research:
     [  ]  c) My entire body, for anatomical or medical study, if needed.

Limitations or special wishes: [enter any special provisions governing donation]

Signed by the donor and following two witnesses, in the presence of each other.

_____________________________       _____________________________
Signature of Donor                  Birthdate

_____________________________       _____________________________
Date Signed                         City and State

_____________________________       _____________________________
Witness                             Witness