Fill and Sign the Revised Uniform Anatomical Gift Act Donation Connecticut

DOCUMENT OF ANATOMICAL GIFT (Connecticut Revised Statutes 19a-270 et seq. ) I hereby make this anatomical gift, if medically acceptable, to take effect upon my death. I give: (check one)       (1) any needed organs or parts _____ (2) only the following organs or parts _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________ ______ to be donated for: (check one) ______ (1) any of the purposes stated in subsection (a) of section 19a-279f of the general statutes ______ (2) these limited purposes: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________ This gift is made after careful reflection, while I am of sound mind. Any party receiving a duly executed copy or facsimile of this document may rely upon it unless such party has received actual notice of my revocation of it. Date________________________________, 20__. ____________________________________ Signature This document was signed in our presence by ______________________________ ________________________________________ the author of this document, who appeared to be eighteen years of age or older, of sound mind and able to understand the nature and consequences of health care decisions at the time this document was signed. The author appeared to be under no improper influence. We have subscribed this document in the author's presence and at the author's request and in the presence of each other. ____________________________________ Witness ____________________________________ Number and Street ____________________________________ City, State and Zip Code ____________________________________ Witness ____________________________________ Number and Street ____________________________________ City, State and Zip Code I, the witness, swear that I am not related to the Principal by blood, marriage, or adoption; and that I am not entitled to any portion of the estate of the Principal under the Principal's current will or codicil, or under any current trust instrument of the Principal ____________________________________ Witness STATE OF CONNECTICUT COUNTY OF ______________ We, the subscribing witnesses, being duly sworn, say that we witnessed the execution of these health care instructions, the appointments of a health care agent and an attorney-in-fact, the designation of a conservator for future incapacity and a document of anatomical gift by the author of this document; that the author subscribed, published and declared the same to be the author's instructions, appointments and designation in our presence; that we thereafter subscribed the document as witnesses in the author's presence, at the author's request, and in the presence of each other; that at the time of the execution of said document the author appeared to us to be eighteen years of age or older, of sound mind, able to understand the nature and consequences of said document, and under no improper influence, and we make this affidavit at the author's request this _______ day of ______________, ___________. ____________________________________ Witness ____________________________________ Witness Subscribed and sworn to before me this ______ day of _____________, __________. __________________________________________ Commissioner of the Superior Court/Notary Public My commission expires: _________________