Fill and Sign the Act of Donation Manual Gift Louisiana Department Form

ANATOMICAL GIFT ACT DONATION (Louisiana Revised Statutes 17:2354) I am of sound mind and 18 years or more of age. I hereby make this anat omical gift to take effect upon my death. The marks in the appropriate squares and words filled i nto the blanks below indicate my desires. In the event of my death, I donate the following part(s) of my body TISSUE: Eyes Bone and connective tissue Skin Heart Other: __________________________________________________________ Limitations: __________________________________________________________ ORGAN: Heart Kidney(s) Liver Lung(s) Pancreas Other: __________________________________________________________ Limitations: __________________________________________________________ To the following person or institutions [ ] the physician in attendance at my death; [ ] the hospital in which I die; [ ] the following named physician, hospital, storage bank or other medical institution __________________________________________________________; [ ] the following individual for treatment __________________________________________________________; for the following purposes: [ ] any purpose authorized by law; [ ] transplantation; [ ] therapy; [ ] research; [ ] medical education. Signed this day of , ___________________, 20 . Signature __________________________________________________________ Place __________________________________________________________ If the donor or other person is physically unable to sign a record, the record ma y 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 dir ection of the declarant after having witnessed the signature of the declarant, have no interest in the esta te of the declarant under the laws of intestate succession or any will or the declarant or codic il thereto, and are not financially responsible for the declarant’s care. Witness Signature: ________________________________________________________ Witness Name: ___________________________________________ Address: __________________________________________________________ Witness Signature: ________________________________________________________ Witness Name: ___________________________________________ Address: __________________________________________________________ ACKNOWLEDGEMENT FORM State of Louisiana Parish of _______________________________ On this _____ day of _______________________ , 20 _____ , before me personally appeared _______________________________ , to me known to be the person (or persons) described in and who executed the foregoing instrument, and acknowledged that (he/she/they) executed it as (his/her/their) free act and deed. _________________________________ Notary Public Print Name: _______________________________