Fill and Sign the Massachusetts Anatomical Gift Form

DOCUMENT OF ANATOMICAL GIFT (General Laws of Massachusetts, Chapter 113A, Sections 4 through 10) I am at least 18 years of age and 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. 1. I give: ______ my body; ______ any needed organs or parts; ______ the following organs or parts _________________________ _________________________ _________________________ 2. To the following person, agency, or institution: ______ any person, tissue bank, or institution authorized by law; ______ the following named physician, hospital, tissue bank or other medical institution _________________________________________________ _________________________________________________ _________________________________________________ 3. For the following purposes: ______ any purpose authorized by law; ______ transplantation; ______ therapy; ______ medical research and education. Donor's Signature: ______________________________________________________________ Address: _________________________________________________ Date: ________________ Signed by the Donor in the presence of the following who sign as witnesses: Witness's Signature: _____________________________________________________________ Address: _________________________________________________ Date: ________________ Witness's Signature: _____________________________________________________________ Address: _________________________________________________ Date: ________________ In the case of a gift of a living donor intended for transplantation, the donor shall authorize such gift in a document signed by the donor and also by at least two of the physicians who are to participate in the transplantation operation and who shall have previously examined the donor in connection with his gift. Physician’s Signature: ______________________________________________ Physician’s Signature: _____________________________________________