Fill and Sign the Revocation of Anatomical Gift Donation Kansas 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 KSA 65-3225 which provides that an anatomical gift may be revoked as follows: (a) Subject to K.S.A. 2017 Supp. 65-3227, and amendments thereto, a donor or other person authorized to make an anatomical gift under K.S.A. 2017 Supp. 65-3223 and amendments thereto, may amend or revoke an anatomical gift by: (1) A record signed by: (A) The donor; (B) the other person; or (C) subject to subsection (b), another individual acting at the direction of the donor or the other person if the donor or other person is physically unable to sign; or (2) a later-executed document of gift that amends or revokes a previous anatomical gift or portion of an anatomical gift, either expressly or by inconsistency. (b) A record signed pursuant to subsection (a)(1)(C) 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). (c) Subject to K.S.A. 2017 Supp. 65-3227, and amendments thereto, a donor or other person authorized to make an anatomical gift under K.S.A. 2017 Supp. 65-3223, and amendments thereto, may revoke an anatomical gift by the destruction or cancellation of the document of gift, or the portion of the document of gift used to make the gift, with the intent to revoke the gift. (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). (f) A donor may revoke or amend an anatomical gift made by placing such individual's name on the first person consent organ and tissue donor registry by directly accessing the registry website or notifying the Kansas federally designated organ procurement organization to request the amendment or revocation. Withdrawal of such individual's consent to be listed in the registry does not constitute a refusal to make an anatomical gift of the individual's body or part. 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: __________________________________________________ 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: __________________________________________________