Fill and Sign the Revised Uniform Anatomical Gift Act Donation Maryland

ANATOMICAL GIFT BY A LIVING DONOR (Maryland Code, Estates and Trusts 4-501 et seq. ) I am at least 18 years of age and make this anatomical gift to take effect upon my death. The marks in the appropriate squares and words filled into the blanks below indicate my desires. 1. I give: [ ] my body; [ ] any needed organs or parts; [ ] the following organs or parts _________________________________________________________________ 2. To the following person, agency, or institution: [ ] any person, tissue bank, or institution authorized by law; [ ] the Anatomy Board of Maryland; [ ] the following named physician, hospital, tissue bank or other medical institution _________________________________________________________________ 3. For the following purposes: [ ] any purpose authorized by law; [ ] transplantation; [ ] therapy; [ ] medical research and education. Donor's Signature: ______________________________________________________________ Address: _________________________________________________________________________ Date: _____________________________________ 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's Signature: _____________________________________________________________ Address: _________________________________________________________________________ Date: _____________________________________ Witness's Signature: _____________________________________________________________ Address: _________________________________________________________________________ Date: _____________________________________