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Fill and Sign the Revised Uniform Anatomical Gift Act Donation Vermont

Fill and Sign the Revised Uniform Anatomical Gift Act Donation Vermont

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REVISED UNIFORM ANATOMICAL GIFT ACT DONATION (18 V.S.A. § 5250e) In the event of my death, I donate the following part(s) of my body for the purposes identified in the Vermont Statutes Annotated 18 V.S.A. § 5250k: 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: 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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