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Fill and Sign the Anatomical Gift Form 497322584

Fill and Sign the Anatomical Gift Form 497322584

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ANATOMICAL GIFT BY A RELATIVE OR THE GUARDIAN OF THE PERSON OF THE DECEDENT (Ohio Revised Code, Chapter 2108) I hereby make this anatomical gift from the body of ____________________________________ (name) who died on ______________________________ (date) in ___________________________________________ (city and state). The marks in the appropriate squares and the words filled into the blanks below indicate my relationship to the decedent and my desires respecting the anatomical gift. 1. I survive the decedent as: 1.       spouse; 2.       adult son or daughter; 3.       parent; 4.       adult brother or sister; 5.       grandparent; 6.       guardian of the person; 7.       person authorized to dispose of the body 8.       person exhibiting special care and concern for the decedent 9.       adult granddaughter or grandson 2. I hereby give the following body parts:       heart       liver       skin       middle ear       kidneys       lung       heart valves       other __________________________________________       pancreas       eyes       bone/ligament for:       any purpose authorized by law       transplantation       therapy       medical research and education 3. After the donated organs, tissues, or eyes are removed, the remains of the body shall be disposed of in the following manner: ____________________________________________________________ ; at the expense of the following person: _______________________________________________________ ; Date: ___________________________ City and State: ___________________________________________________________________ Signature of Survivor ________________________________________________ Signature of Witness ________________________________________________ Signature of Witness ________________________________________________

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The best way to complete and sign your anatomical gift form 497322584

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