Fill and Sign the Donor Form

DONATION PURSUANT TO THE OHIO REVISED UNIFORM ANATOMICAL GIFT ACT In the event of my death, I donate the following part(s) of my body for the purposes identified in the Ohio Revised Code 2108.11: TISSUE:       Eyes       Bone and connective tissue       Skin       Heart Other: _____________________________________ Limitations: _____________________________________ ORGAN:       Heart       Kidney(s)       Liver       Lung(s)       Pancreas Other: _____________________________________ Limitations: _____________________________________ Signed this day of _______, ____, 20       . Signature __________________________________________________________ Place _____________________________________ 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: ACKNOWLEDGEMENT FORM State of Ohio Judicial District ______________________________ 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: This is a legal document under the Revised Uniform Anatomical Gift Act or similar laws. DONOR REGISTRY ENROLLMENT FORM (OPTIONAL) To register for the Donor Registry, please complete this form and send it to the Ohio Bureau of Motor Vehicles. This form must be signed by two witnesses. If the donor is under age eighteen, one witness must be the donor’s parent or legal guardian.       Please include me in the donor registry.       Please remove me from the donor registry. Full Name (please print) _____________________________________ Mailing Address _____________________________________ _____________________________________ _____________________________________ Phone ___________________ Date of Birth ___________________ Driver’s License or ID Card No. ___________________ Social Security No. ___________________ On my death, I make an anatomical gift of my organs, tissues, and eyes for any purpose authorized by law. OR On my death, I make an anatomical gift of the following specified organs, tissues, or eyes for any purposes indicated below. Purposes: Any purpose authorized by law Transplantation Therapy Research Education Advancement of medical science Advancement of dental science ________________________________________ _______________ Signature of donor registrant Date ________________________________________ ______________________________ Witness Signature Witness Signature