Fill and Sign the Revocation of Anatomical Gift Donation Iowa Form

REVOCATION OF DONATION PURSUANT TO THE REVISED UNIFORM ANATOMICAL GIFT ACT 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 Idaho Iowa Code Chapter 142C, which provides that an anatomical gift may be revoked by: a. A signed statement, executed by the donor. b. An oral statement made by the donor in the presence of two individuals. c. Any form of communication during a terminal illness or injury addressed to a health care professional, licensed or certified pursuant to chapter 148, 148C, 150A, or 152. d. The delivery of a written statement, signed by the donor, to a specified donee to whom a document of gift has been delivered. 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 the       day of       , 20       , Signature of Declarant: __________________________________________________________ Printed Name of Declarant:       Address of Declarant:       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:       Serial Number, if any: