Fill and Sign the Uniform Anatomical Gift Act the Donate Life Colorado

DONATION PURSUANT TO THE COLORADO REVISED UNIFORM ANATOMICAL GIFT ACT (Colorado Revised Statutes 12-34-101 et seq.) In the event of my death, I donate the following part(s) of my body for the purposes identified in the Colorado Revised Statutes 12-34-104: TISSUE: Eyes Bone and connective tissue Skin Heart Other: _______________________________________________________________Limitations: _______________________________________________________________ORGAN: Heart Kidney(s) Liver Lung(s) Pancreas Other: _______________________________________________________________Limitations: _______________________________________________________________Signed this day of , _____________________, 20 . Signature__________________________________________________________ Place_______________________________________________________________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: ACKNOWLEDGEMENT FORM State of _________________Judicial District _________________The foregoing instrument was acknowledged before me this _________________ (date) by _________________. (name of person who acknowledged). Signature of Person Taking Acknowledgement:_______________________________________________Title or Rank: Serial Number, if any: