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Fill and Sign the Revocation of Anatomical Gift Donation Wisconsin Form

Fill and Sign the Revocation of Anatomical Gift Donation Wisconsin Form

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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 Wisconsin Statutes 157.06(2), which provides that an anatomical gift may be revoked by: 157.06(2)(f)1. 1. Signing a statement of amendment or revocation. 157.06(2)(f)1m. 1m. Signing a new document of gift. Signing a new document of gift revokes any previously signed document of gift. 157.06(2)(f)2. 2. Verbally amending or revoking in the presence of 2 individuals. 157.06(2)(f)3. 3. During the donor's terminal illness or injury making, by any form Of communication that is addressed to a physician, an amendment or revocation. 157.06(2)(f)4. 4. Delivering a signed statement of amendment or revocation to a specified donee to whom a document of gift had been delivered. 157.06(2)(f)5. 5. Crossing out or amending the donor authorization or refusal in the space provided on his or her license as prescribed in s. 343.175 (2) or identification card as prescribed in s. 343.50 (3). 157.06(2)(f)6. 6. Revoking the provision of a power of attorney for health care instrument that makes an anatomical gift or revoking that power of attorney for health care instrument. 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: ___________________________________________________________

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