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Fill and Sign the 20 Do Hereby Revoke Such Gift Pursuant to Oklahoma Statutes Form

Fill and Sign the 20 Do Hereby Revoke Such Gift Pursuant to Oklahoma Statutes Form

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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 Oklahoma Statutes § 63-2201.6, which provides that an anatomical gift may be revoked at any time by: 1. A record signed by: a. the donor, b. the other person, or c. subject to subsection B, another individual acting at the direction of the donor or the other person if the donor or other person is physically unable to sign; or 2. A later-executed document of gift that amends or revokes a previous anatomical gift or portion of an anatomical gift, either expressly or by inconsistency. 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: ________________________________________________________________________________________________

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