Fill and Sign the Arkansas Uniform Anatomical Gift Act Lawuniform Acts

DONATION PURSUANT TO THE ARKANSAS REVISED UNIFORM ANATOMICAL GIFT ACT (Arkansas Code 20-17-120i et seq.) In the event of my death, I donate the following part(s) of my body for the purposes identified in Arkansas Code 20-17-1211: 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 witnessed 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 witnesses 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 thereto, and are not financially responsible for the declarant’s care.Witness Signature: ________________________________________________________Witness Name:Address:Witness Signature: ________________________________________________________Witness Name:Address:State of _______________Judicial District _______________ ACKNOWLEDGEMENT FORM The foregoing instrument was acknowledged before me this ____________________ (date) by ________________________________ (name of person who acknowledged). Signature of Person Taking Acknowledgement:_______________________________________________Title or Rank:Serial Number, if any: