Fill and Sign the Change the Uniform Anatomical Gift Act in Alabama to

DONATION PURSUANT TO THE ALABAMA REVISED UNIFORM ANATOMICAL GIFT ACT (Alabama Code 22-19-161 et seq.) In the event of my death, I donate the following part(s) of my body for the purposes identified in Alabama Code 22-19-170:TISSUE:__________ Eyes __________ Bone and connective tissue __________ Skin __________ Heart Other: _____________________________________________________________ Limitations: _____________________________________________________________ ORGAN:__________Heart __________Kidney(s) __________Liver __________Lung(s) __________ Pancreas Other: _____________________________________________________________Limitations: _____________________________________________________________Signed this day of ________ of _________________________________, 20___________. Signature__________________________________________________________ Place_____________________________________________________________If another person is to sign for the declarant at the declarant's direction, the person signing for the declarant must sign in the presence of two witnesses. The witness form below may be used for the two witnesses. The acknowledgement form below may be used for the person qualified to take acknowledgements. WITNESS FORM The following witnesses declare that the signature above was made at the donor’s request:Witness Signature: ________________________________________________________Witness Name: ___________________________________________________________Address: ________________________________________________________________Witness Signature: ________________________________________________________Witness Name: ___________________________________________________________Address: ________________________________________________________________ADDITIONAL STATEMENT OF WITNESSES: At least one of the above witnesses must also sign the following declaration:I further declare under penalty of perjury under the laws of Alabama that I am not related to the individual executing this advance health care directive by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the individual's estate upon his or her death under a will now existing or by operation of law. Signature of Witness: ___________________________________________Signature of Witness: ___________________________________________ 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: _____________________________