Fill and Sign the 20 Do Hereby Revoke Such Gift Pursuant to Hawaii Revised Form

REVOCATION OF ANATOMICAL GIFT I, ___________________________________________________________________, Declarant, having made an anatomical gift by virtue of that document of gift dated the ________ day of ________________________, 20___, do hereby revoke such gift pursuant to Hawaii Revised Statutes §327-1 et seq., which provides that an anatomical gift may be revoked as follows: (a) A person authorized to make an anatomical gift under section 327-9 may make an anatomical gift by a document of gift signed by the person making the gift or that person's oral communication that is electronically recorded or is contemporaneously reduced to a record and signed by the individual receiving the oral communication. (b) Subject to subsection (c), an anatomical gift by a person authorized under section 327-9 may be amended or revoked orally or in a record by any member of a prior class who is reasonably available. If more than one member of the prior class is reasonably available, the gift made by a person authorized under section 327-9 may be amended or revoked only if a majority of the reasonably available members of that class agree to the amending or revoking of the gift or they are equally divided as to whether to amend or revoke an anatomical gift. (c) A revocation under subsection (b) is effective only if the procurement organization or transplant hospital or the physician or technician knows of the revocation before an incision has been made to remove a body part from the donor, or before invasive procedures have begun to prepare the recipient.This is my written revocation of my anatomical gift and is provided to all persons to whom I have provided a copy of my document of anatomical gift.DATED this the _________ day of ______________________________, 20____.Signature of Declarant: __________________________________________________________Printed Name of Declarant: _______________________________________________________Address of Declarant: ___________________________________________________________