UNIFORM DONOR CARD

OF _________________________________________________________
(print or type name of donor)
ADDRESS __________________________________________________
CITY/STATE _______________________________________________
In the hope that I may help others, I hereby make this anatomical gift,
if medically acceptable, to take effect upon my death. I give:
(a) _____ any needed organs or parts
(b) _____ only the following organs or parts
_____________________________________________________________
_____________________________________________________________
(specify the organ[s] or part[s])
for the purpose of transplantation, therapy, medical research or education
(c) _____ my body for anatomical study if needed.
Limitations or special wishes, if any:
______________________________________________________________



SIGNED BY THE DONOR AND THE FOLLOWING TWO WITNESSES
IN THE PRESENCE OF EACH OTHER:

_______________________________________________________________
signature of donor & date of birth
_______________________________________________________________
date signed & city and state
_______________________________________________________________
witness
_______________________________________________________________
witness

This is a legal document under the Uniform Anatomical Gift Act