Fill and Sign the Chapter 86 Pa General Assembly Form

UNIFORM ANATOMICAL GIFT ACT DONATION (Pennsylvania Consolidated Statutes 20-8613) I am of sound mind and 18 years or more of age. I hereby make this anatomical gift to take effect upon my death. The marks in the appropriate squares and words filled into the blanks below indicate my desires. I give: [____] my body; [____] any needed organs or parts; [____] the following organs or parts______________________________________________________________________________________________________________________________________;To the following person or institutions [____] the physician in attendance at my death; [____] the hospital in which I die; [____] the following named physician, hospital, storage bank or other medical institution ___________________________________________________________;[____] the following individual for treatment ___________________________________________________________________;for the following purposes: [____] any purpose authorized by law; [____] transplantation; [____] therapy; [____] research; [____] medical education. Dated __________________________ City and State _________________________________Signed by the Donor in the presence of the following who sign as witnesses. Signature of Donor: _____________________________________________________________ Address of Donor: __________________________________________________________Witness: ______________________________________________________________________Witness: ______________________________________________________________________