Fill and Sign the Anatomical Gift Act Form

DONATION PURSUANT TO THE CALIFORNIA UNIFORM ANATOMICAL GIFT ACT (California Health and Safety Code 7150-7151) In the event of my death, I donate the following part(s) of my body for the purposes identified in the California Health and Safety Code 7150-7151: 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 another person is to sign for the declarant at the declarant's direction, the person signing for the declarant must sign in the presence of two witnesses. The witness form below may be used for the two witnesses. The acknowledgement form below may be used for the person qualified to take acknowledgements. WITNESS FORM The following witnesses declare that the signature above was made at the donor’s request: Witness Signature: ________________________________________________________ Witness Name: ___________________________________________________________ Address: ________________________________________________________________ Witness Signature: ________________________________________________________ Witness Name: ___________________________________________________________ Address: ________________________________________________________________ ADDITIONAL STATEMENT OF WITNESSES : At least one of the above witnesses must also sign the following declaration: I further declare under penalty of perjury under the laws of California that I am not related to the individual executing this advance health care directive by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the individual's estate upon his or her death under a will now existing or by operation of law. Signature of Witness: ___________________________________________ Signature of Witness: ___________________________________________ A notary public or other office completing this certificate Verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of       On       , 20       before me,       (here insert name and title of the officer), personally appeared __________________________ , who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity , and that by his signature on the instrument the person , or the entity upon behalf of which the person acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature (Seal) Notary Public