Fill and Sign the Revocation of Anatomical Gift Donation North Carolina 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 North Carolina General Statutes § 130A-412.8, which provides that an anatomical gift may be revoked at any time 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 authorized to make an anatomical gift 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 under subsection (a)(1)(C) must: (1) be witnessed by two (2) adults, at least one (1) of whom is a disinterested witness, who are witnesses at the request of the donor or the other person authorized to make an anatomical gift; and (2) state that the record has been signed and witnessed as described in subdivision (1). 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: