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Fill and Sign the 765514 Statutes Ampamp Constitution View Statutes Online Form

Fill and Sign the 765514 Statutes Ampamp Constitution View Statutes Online Form

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DONOR CARD PER7 Donor _________________________________In the hope that I may help others, I hereby make this anatomical gift, if medically acceptable, to take effect on my death. The words and marks below indicate my desire.I give to: _________________________________ Any needed organs or parts. Only the following organs or parts for the purpose of transplantation, therapy, or medical research or education. __________________________________________________________________________________________ My body for anatomical study, if needed. I designate _________________________________ as surgeon to carry out the appropriate procedures. Limitations or special wishes, if any: __________________________________________ STATE OF ARIZONA ) )ss County of __________________________ )Signed by donor and the following two witnesses in the presence of each other at _________________________________ on this ________________ day of ________________, 20 _____._______________________________________________________ _____________________________Donor Date of BirthNotary Public ________________________ ____________________ (Seal)WITNESSES:______________________________SignaturePrint Name: __________________________Address: __________________________City: _______________ State: _______ Zip: _______WITNESSES:______________________________SignaturePrint Name: __________________________Address: __________________________ City: ________________ State: _______ Zip: _______

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