Uniform Anatomical Gift Act Donation (Generic) {POA 203}

DONATION PURSUANT TO THE DELAWARE UNIFORM ANATOMICAL GIFT ACT In the event of my death, I donate the following part(s) of my body for the purposes identified in [specify state act relating to anatomical gift] for anatomical gifts and studies: 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 Name Signature Place WITNESS: If another person is to sign for the declarant at the declarant's direction, the person signing for the declarant must sign in the presence of two witnesses. The witness form below may be used for the two witnesses. The acknowledgement form below may be used for the person qualified to take acknowledgements. WITNESS FORM The following witnesses declare that the signature above was made at the donor's request: Witness Signature: Witness Name: Address: Witness Signature: Witness Name: Address: ADDITIONAL STATEMENT OF WITNESSES: At least one of the above witnesses must also sign the following declaration: I further declare under penalty of perjury under the laws of that I am not related to the individual executing this advance health care directive by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the individual's estate upon his or her death under a will now existing or by operation of law. Signature of Witness: Signature of Witness: State of County of On before me, (here insert name and title of the officer), personally appeared , who 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. I certify under PENALTY OF PERJURY under the laws of the State of that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature: (Seal) American LegalNet, Inc. 251 www.FormsWorkFlow.com