Fill and Sign the Revised Uniform Anatomical Gift Act Donation Indiana

DONATION PURSUANT TO THE REVISED UNIFORM ANATOMICAL GIFT ACT (Indiana Code 29-2-16.1-1 et seq. ) In the event of my death, I donate the following part(s) of my body for the purposes identified in Indiana Code 29-2-16.1-3. 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 declarant 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: ________________________________ 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:     FORMTEX T ____________     Serial Number, if any:     FORMTEX T ____________