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Fill and Sign the Anatomical Gift Registry Application Form We

Fill and Sign the Anatomical Gift Registry Application Form We

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Open the document and fill out all its fields.
Apply your legally-binding eSignature.
Save and invite other recipients to sign it.

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Anatomical Gift by Next of Kin1 ANATOMICAL GIFT BY NEXT OF KIN,GUARDIAN, AGENT, OR SURROGATE Under AS 13.52.180 et seq., I make this anatomical gift from the body of_________________________________________________________________ (name of decedent)who died on {Insert Date} at _________________________________________ (place) (city)in _______________________________________________________________ . (state) The marks in the appropriate squares and the words filled into the blanks below indicate my relationship to the decedent and my wishes respecting the gift.I survive the decedent as spouse; adult son or daughter; parent; adult brother or sister; grandparent; or I am the decedent's agent under AS 13.52 or surrogate under AS 13.52. I hereby give (check boxes applicable): any needed organs, tissues, or parts; the following organs, tissues, or parts only: _____________________________________________________; the following purposes only: _____________________________________________________ Anatomical Gift by Next of Kin2___________________________________________________(date) (signature of survivor)_____________________________________________________ (address of survivor)

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