Fill and Sign the Arizona Revised Uniform Anatomical Gift Act Donation

DONATION PURSUANT TO THE REVISED ARIZONA ANATOMICAL GIFT ACT (Arizona Revised Statutes 36 -841 to 36 -850) In the event of my death, I donate the following part(s) of my body for the purposes identified in Arizona Revised Statutes 36 -850: TISSUE: Eyes Bone and connective tissue Skin Heart Other: _______________________________________________________________ Limitations: _______________________________________________________________ ORGAN: Heart Kidney(s) Liver Lung(s) Pancreas Other: ___________________________ ____________________________________ Limitations: _______________________________________________________________ Signed this day of , ______________________ , 20 . Signature __________________________________________________________ Place _______________________________________________________________ If the donor or other person is physically unable to sign a record, the record may be signed by another individual at the direction of the donor or other person and must: (1) be wit nessed by at least two adults, at least one of whom is a disinterested witness, who have signed at the request of the donor or the other person; and (2) state that it has been signed and witnessed as provided in paragraph (1). WITNESS FORM The witness es below declare that they are signing at the direction of the declarant after having witnessed the signature of the declarant, have no interest in the estate of the declarant under the laws of intestate succession or any will or the declarant or codicil t hereto, and are not financially responsible for the declarant’s care. Witness Signature: ________________________________________________________ Witness Name: Address: Witness Signature: ________________________________________________________ Witness Name: Address: