Fill and Sign the Georgia Revocation of Anatomical Gift Act Donation 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 to the Georgia Code §44 -5-147, which pro vides that an anatomical gift may be revoked as follows: (a) If the document of gift or an executed copy thereof has been delivered to a specified donee, the donor may amend or revoke the gift by: (1) The execution and delivery to the donee of a s igned statement; (2) An oral statement made in the presence of two persons and communicated to the donee; (3) A statement during a terminal illness or injury, which statement is addressed to an attending physician and communicated to the donee; o r (4) A signed card or document found on his person or in his effects. (b) Any document of gift which has not been delivered to the donee may be revoked by the donor in the manner set out in subsection (a) or by the destruction, cancellation, or mutilation of the document and all executed copies thereof. (c) Any gift made by a will may also be amended or revoked in the manner provided for the amendment or revocation of wills or as provided in subsection (a). This is my written revocation o f 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: ___________________________________________________________ Signed and executed in the presence of: _________________________________ __________________________________ Witness Witness