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Fill and Sign the 71 4825 Terms Defined for Purposes of the Revised Uniform

Fill and Sign the 71 4825 Terms Defined for Purposes of the Revised Uniform

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REVISED UNIFORM ANATOMICAL GIFT ACT DONATION (North Dakota Century Code 23-06.6-04) I am of sound mind and 18 years or more of age. I hereby make this anatomical gift to take effect upon my death. The marks in the appropriate squares and words filled into the blanks below indicate my desires. TISSUE: Eyes Bone and connective tissue Skin Heart Other: ___________________________________________ Limitations: ___________________________________________ ORGAN: Heart Kidney(s) Liver Lung(s) Pancreas Other: ___________________________________________Limitations: ___________________________________________ Signed this day of , ____________________________ , 20 , Signature__________________________________________________________ Place___________________________________________ If the donor or other person is physically unable to sign a record, the record may be signed by another individual at the direction of the donor or other person and must: (1) be witnessed by at least two adults, at least one of whom is a disinterested witness, who have signed at the request of the donor or the other person; and (2) state that it has been signed and witnessed as provided in paragraph (1). WITNESS FORM The witnesses below declare that they are signing at the direction of the declarant after having witnessed the signature of the declarant, have no interest in the estate of the declarant under the laws of intestate succession or any will or the declarant or codicil thereto, and are not financially responsible for the declarant’s care.Witness Signature: ________________________________________________________Witness Name:Address:Witness Signature: ________________________________________________________Witness Name:Address:State of _______________________Judicial District _______________________ ACKNOWLEDGEMENT FORM The foregoing instrument was acknowledged before me this _______________________ (date) by ______________________________________ (name of person who acknowledged). Signature of Person Taking Acknowledgement:_______________________________________________Title or Rank:Serial Number, if any:

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