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Fill and Sign the Subchapter Ii Uniform Anatomical Gift Act Delaware Code

Fill and Sign the Subchapter Ii Uniform Anatomical Gift Act Delaware Code

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ANATOMICAL GIFT BY A LIVING DONOR (Delaware Code 16-2710 to 16-2719) I am of sound mind and 18 years or more of age. I hereby make this anatomical gift to take effect upon my death. The marks in the appropriate squares and words filled into the blanks below indicate my desires. I give: [_____] my body; [_____] any needed organs or parts; [_____] the following organs or parts__________________________________________________________________ __________________________________________________________________ To the following person or institutions [_____] the physician in attendance at my death; [_____] the hospital in which I die; [_____] the following named physician, hospital, storage bank or other medical institution _________________________________________________;[_____] the following individual for treatment _________________________________________________;for the following purposes: [_____] any purpose authorized by law; [_____] transplantation; [_____] therapy; [_____] research; [_____] medical education. Dated ________________________ City and State ______________________________Signed by the Donor in the presence of the following who sign as witnesses. Signature of Donor: _____________________________________________________________ Address of Donor: ____________________________________________________________Witness: ______________________________________________________________________Witness: ______________________________________________________________________

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