Fill and Sign the Michigan Anatomical 497311668 Form

UNIFORM DONOR CARD of _________________________________________________ print or type name of donor In the hope that I may help others, I hereby make this anatomical gift, if medically acceptable, to take effect upon my death. The words and marks below indicate my desires. I give: (a) _____ any needed organs or parts (b) _____ only the following organs or parts __________________________________________________________________ specify the organ(s) or part(s) for the purposes of transplantation, therapy, medical research, or education; (c) _____ my body for anatomical study if needed. Limitations or special wishes, if any: ___________________________________ _________________________________________________________________ Signed by the donor and the following 2 witnesses in the presence of each other: _________________________________ ____________________________________ Signature of donor Date of birth of donor _________________________________ ____________________________________ Date signed City and State _________________________________ ____________________________________ Witness Witness This is a legal document under the Michigan Uniform Anatomical Gift Act, Michigan Consolidated Laws, 333.10104 to 333.10109.