Fill and Sign the Anatomical Gift Act 497324812 Form

UNIFORM ANATOMICAL GIFT ACT DONATION (Pennsylvania Consolidated Statutes 20-8613) 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. 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 _________________________________ Signed by the Donor in the presence of the following who sign as witnesses. Signature of Donor: _____________________________________________________________ Address of Donor: __________________________________________________________ Witness: ______________________________________________________________________ Witness: ______________________________________________________________________