Fill and Sign the Anatomical Gift Form

ANATOMICAL GIFT BY A LIVING MINOR DONOR (Delaware Code 16-2710 to 16-2719) I am of sound mind and under 18 years of age. I hereby make this anatomical gift to take effect upon my death with the parental consent of the undersigned. The marks in the appropriate squares and the words filled into the blanks below indicate my desires. I give: [ ] my body; [ ] any needed organs or parts; [ ] the following organs or parts__________________________________________________________________________________________________;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. Dated _____________________________ City and State _____________________________The undersigned parent or other person authorized by law grants permission for the above anatomical gift. Signed by the Donor and the person giving parental consent in the presence of the following who sign as witnesses. Signature of Donor: _____________________________________________________________ Address of Donor: _________________________________________________ Signature of Parent or Other Person Authorized by Law: _____________________________________________________________________________Address of Consenting Party: _________________________________________________Witness: ______________________________________________________________________Witness: ______________________________________________________________________