Fill and Sign the Anatomical Gift Act Donation by a Person under 18 Years Old Missouri Form

ANATOMICAL GIFT BY A MINOR DONOR (Missouri Revised Statutes 194.210 to 194.290) 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 to Consent to the Minor's Donation: ______________________________________________________________________________ Address of Consenting Party: _____________________________________________________ Witness: ______________________________________________________________________ Witness: ______________________________________________________________________