Fill and Sign the California Uniform Anatomical Gift Act Donor Network West

REVOCATION OF ANATOMICAL GIFT I, ______________________________, Declarant, having made an anatomical gift by virtue of that document of gift dated the ________ day of __________________________, 20________, do hereby revoke such gift pursuant Florida Statutes §765.516 which provides that an anatomical gift may be revoked as follows: (a) The execution and delivery to the donee of a signed statement witnessed by at least two adults, at least one of whom is a disinterested witness. (b) An oral statement that is made in the presence of two persons, one of whom is not a family member, and communicated to the donor's family or attorney or to the donee. An oral statement is effective only if the procurement organization, transplant hospital, or physician or technician has actual notice of the oral amendment or revocation before an incision is made to the decedent's body or an invasive procedure to prepare the recipient has begun. (c) A statement made during a terminal illness or injury addressed to an attending physician, who must communicate the revocation of the gift to the procurement organization. (d) A signed document found on or about the donor's person. (e) Removing his or her name from the donor registry. (f) A later-executed document of gift which amends or revokes a previous anatomical gift or portion of an anatomical gift, either expressly or by inconsistency. (g) By the destruction or cancellation of the document of gift or the destruction or cancellation of that portion of the document of gift used to make the gift with the intent to revoke the gift. (2) Any anatomical gift made by a will may also be amended or revoked in the manner provided for the amendment or revocation of wills or as provided in paragraph (1)(a). This is my written revocation of my anatomical gift and is provided to all persons to whom I have provided a copy of my document of anatomical gift.DATED this the ________ day of _____________________________, 20________.___________________________________________Name of DeclarantPrinted Name of Declarant: _____________________________Address of Declarant: __________________________________________________________________WitnessPrint Name: __________________________________________________________________ WitnessPrint Name: _____________________________