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Fill and Sign the New Hampshire Revised Statutes 291 A5 Form

Fill and Sign the New Hampshire Revised Statutes 291 A5 Form

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REVISED UNIFORM ANATOMICAL GIFT ACT DONATION (New Hampshire Revised Statutes § 291-A:5) In the event of my death, I donate the following part(s) of my body for the purposes identified in the New Hampshire Statutes 291-A:11: 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 ____________________________ 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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