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Fill and Sign the Revised Uniform Anatomical Gift Act Donation Hawaii

Fill and Sign the Revised Uniform Anatomical Gift Act Donation Hawaii

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DONATION PURSUANT TO THE REVISED UNIFORM ANATOMICAL GIFT ACT (Hawaii Revised Statutes 327-5 et seq. ) In the event of my death, I donate the following part(s) of my body for the purposes identified in Hawaii Revised Statutes 327-11. 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 another person is to sign for the declarant at the declarant's direction, the person signing for the declarant must sign in the presence of two persons or a person who is qualified to take acknowledgments. The witness form below may be used for the two witnesses, one of whom must be disinterested in the estate of the donor.. The acknowledgement form below may be used for the person qualified to take acknowledgements. WITNESS FORM Witness Signature: ________________________________________________________ Witness Name: ___________________________________________________________ Address: ________________________________________________________________ Witness Signature: ________________________________________________________ Witness Name: ___________________________________________________________ Address: ________________________________________________________________ State of ___________________________ Judicial District ____________________ ACKNOWLEDGEMENT FORM 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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