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SAMPLE ORGAN DONOR DECLARATION

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