Fill and Sign the Document of Gift Dated the Day of 20 Do Form

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 the West Virginia Code Section 16-19-6, which provides that an anatomical gift may be revoked by: (1) (A) A record signed and dated by the donor or the authorized person. (B) If the donor or the authorized person is physically unable to sign arecord, another individual may sign at the direction of the donor or theauthorized person if the document of gift: (i) Is witnessed and signed by at least two adults, at least one of whomis a disinterested witness; and (ii) Contains a statement that it has been signed and witnessed asrequired by subparagraph (i) of this paragraph; or (2) A later-executed document of gift that amends or revokes a previousanatomical gift, or portion of an anatomical gift, either expressly or byinconsistency. (b) Subject to section eight of this article, a donor or a personauthorized by section four of this article may revoke an anatomical giftby destroying or cancelling the document of gift, or the relevant portionof the document of gift, with the intent to revoke the gift. (c) During a terminal illness or injury, a donor may amend or revoke ananatomical gift that was not made in a will by any form of communicationaddressed to at least two adults, at least one of whom is a disinterestedwitness. (d) A donor who makes an anatomical gift in a will may amend or revokethe gift in the manner provided for amendment or revocation of wills oras provided in subsection (a) of this section.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 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: