Fill and Sign the Anatomical Gift Act 497431244 Form

UNIFORM ANATOMICAL GIFT ACT DONATION (Wisconsin Statutes 157.06(2)) 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: ______________________________________________________________________