Fill and Sign the Revocation of Anatomical Gift Donation Maryland Form

REVOCATION OF ANATOMICAL GIFT 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 Maryland Code, Estates and Trusts 4-504, which provides that an anatomical gift may be revoked at any time by: (1) a record signed by: (i) the donor; (ii) the other person; or (iii) subject to subsection (b) of this section, if the donor or other person is physically unable to sign, another individual acting at the direction of the donor or the other person; or (2) a later-executed document of gift that expressly or by inconsistency amends or revokes the previous anatomical gift or portion of the anatomical gift. (b) a record signed in accordance with subsection (a)(1)(iii) of this section shall: (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 the record has been signed and witnessed as provided in item (1) of this subsection. 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: