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Fill and Sign the Nevada Uniform Anatomical Gift Act Donor Network West

Fill and Sign the Nevada Uniform Anatomical Gift Act Donor Network West

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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 Tennessee Code Annotated, § 68-30-106, which provides that an anatomical gift may be revoked as follows: (a) A donor may amend or revoke an anatomical gift, not made by will, by: (1) A signed statement; (2) An oral statement made in the presence of two (2) individuals; (3) Any form of communication by a terminal patient addressed to a physician; or (4) The delivery of a signed statement to a specified donee to whom a document of gift had been delivered. (b) A donor who makes an anatomical gift in a will may amend or revoke the gift in the manner provided for amendment or revocation of wills or as provided in subsection (a). This is my written revocation of 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: 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:

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