Fill and Sign the Connecticut General Statutes 19a 575aform of Document

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 to the California Health and Safety Code §7150.25, which provides that an anatomical gift may be revoked by: (1) A record signed by any of the following and recorded in a donor registry database: (A) The donor. (B) The other person. (C) Subject to subdivision (b), another individual acting at the direction of the donor or of the other person, if the donor or other person is physically unable to sign. (2) A later-executed document of gift that amends or revokes a previous anatomical gift or portion of an anatomical gift, either expressly or by inconsistency.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____.Signature of Declarant: __________________________________________________________Printed Name of Declarant: _______________________________________________________Address of Declarant: ___________________________________________________________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 persons or a person who is qualified to take acknowledgments. 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 signatures below are 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 California 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: ___________________________________________ A notary public or other office completing this certificate Verifies only the identity of the individual who signedthe document to which this certificate is attached, andnot the truthfulness, accuracy, or validity of that document.State of CaliforniaCounty of On , 20 before me, (here insert name and title of the officer), personally appeared , who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.WITNESS my hand and official seal.Signature (Seal) Notary Public