Fill and Sign the Uniform Anatomical Gift Act Donation Declaration Idaho

ANATOMICAL GIFT BY NEXT OF KIN OR GUARDIAN OF THE PERSON (Idaho Code 39-3410) Pursuant to the Uniform Anatomical Gift Act, I hereby make this anatomical gift from the body of ________________________________________________________________ who died on ___________________________________ at ___________________________________ in ___________________________________ . The marks in the appropriate squares and the words filled into the blanks below indicate my relationship to the decedent and my wishes respecting the gift. I survive the decedent as spouse; adult son or daughter; adult brother or sister; grandparents guardian of the person. I hereby give (check boxes applicable): 1. Any needed organs, tissues, or parts; 2. The following organs, tissues, or parts only ________________________________________________________________ 3. [ ] For the following purposes only ________________________________________________________________ (transplant-therapy-research-education) Date: ___________________________________ Signature of Survivor: ___________________________________________________________ Printed Name of Survivor: ___________________________________________________ Address of Survivor: ___________________________________________________ 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: State of ____________________ Judicial District ____________________ ACKNOWLEDGEMENT FORM 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: