Fill and Sign the Revocation of Anatomical Gift Donation Pennsylvania 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 Pennsylvania Consolidated Statutes 20-8615, which provides that an anatomical gift may be revoked by: (a) If the will, card, or other document or executed copy thereof has been delivered to a specified donee, the donor may amend or revoke the gift by any of the following: 1. The execution and delivery to the donee of a signed statement; 2. An oral statement made in the presence of two persons and communicated to the donee; 3. A statement during a terminal illness or injury addressed to an attending physician and communicated to the donee. 4. A signed card or document found on his person or in his effects. (b) Any document of gift which has not delivered to the donee may be revoked by the donor in the manner set out in subsection (a) or by destruction, cancellation, or mutilation of the document and all executed copies thereof. 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: ___________________________________________________________