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Fill and Sign the Nebraska Revised Uniform Anatomical Gift Act

Fill and Sign the Nebraska Revised Uniform Anatomical Gift Act

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DONATION PURSUANT TO THE NEBRASKA 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 Nebraska Revised Statutes: 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 decla rant 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 Nebraska 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: _________________

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