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Fill and Sign the Revocation of Anatomical Gift Donation Connecticut Form

Fill and Sign the Revocation of Anatomical Gift Donation Connecticut Form

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REVOCATION OF DOCUMENT OF ANATOMICAL GIFT (Connecticut Revised Statutes 19a-270 et seq. ) I, ___________________________________________________________________, Declarant, having made an anatomical gift by virtue of that document of gift dated the ________ day of ________________________, 20___, do hereby revoke such gift pursuant to Connecticut Revised Statutes Sec. 19a-279b, which provides that: d) A donor may amend or revoke an anatomical gift that was not made in a will by any form of communication during a terminal illness or injury addressed to at least two adults, at least one of whom is a disinterested witness. (e) A donor who makes an anatomical gift in a will may amend or revoke the gift in the manner provided for amendment or revocation of wills or as provided in subsection (a) of this section. This is my written revocation of my anatomical gift and is provided to all persons to whom I have provided a copy of my document of anatomical gift. DATED this the _________ day of ______________________________, 20____. Signature of Declarant: __________________________________________________________ Printed Name of Declarant: _______________________________________________________ Address of Declarant: ___________________________________________________________ Signature of Witness: ____________________________________________________ Printed Name of Witness: _________________________________________________ Address of Witness: _____________________________________________________ Signature of Witness: ____________________________________________________ Printed Name of Witness: _________________________________________________ Address of Witness: _____________________________________________________ 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

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