“Help us to stay online by your kind donation.
Every penny will help.”
Organ Donation Form
I, [Name], of [Address], give my organs, tissues, or parts as directed below. This Anatomical Gift will take effect upon my death.
I give: (initial one of the three options)
[ ] any needed organs, tissues, or parts.
[ ] any needed organs, tissues, or parts except:
[ ] the following organs, tissues, or parts only:
I give my organs, tissues, or parts indicated above to be used for: (initial one of the two options)
[ ] any purpose authorized by law.
[ ] the following purposes only: (initial all that apply)
[ ] transplantation
[ ] research
[ ] therapy
[ ] education
Limitations or special wishes, if any:None.
If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
Donor's Date of Birth:
I witnessed that this document was signed in my presence by the Donor. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:
*** If Required By State Law ***
This Section for Notary:
STATE OF -------)
) ss: [date]
COUNTY OF ------)
On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Witness my hand and official seal.
[Name of Notary Public]
My commission expires: [date]