Fill and Sign the Wyoming Uniform Act

UNIFORM ANATOMICAL GIFT ACT DONATION (Wyoming Statutes 35-5-102) I am of sound mind and under 18 years of age. I hereby make this anatomical gift to take effect upon my death with the parental consent of the undersigned. The marks in the appropriate squares and the 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 _______________________________________ The undersigned parent or other person authorized by law grants permission for the above anatomical gift. Signed by the Donor and the person giving parental consent in the presence of the following who sign as witnesses. Signature of Donor: _____________________________________________________________ Address of Donor: ________________________________________________________ Signature of Parent or Other Person Authorized by Law: ______________________________________________________________________________ Address of Consenting Party: ________________________________________________________ Witness: ______________________________________________________________________ Witness: ______________________________________________________________________