Maine Health Care Advance Directive Form Page 10
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14Part 4 – Donation of Body,
Organs or Tissues at Death
This section is optional. Fill out this part only if you want to give directions about donating your body,
organs or tissues after your death.
I do NOT wish to donate any organs, tissues or parts.
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I have checked below my choices about donating my body, organs or tissues after death. I have spoken with my
.
family so that they will not object to my wishes after I die
I give my body. OR
I give any needed organs, tissues or parts. OR
I give only the following organs, tissues, or parts:
____________________________________________________________________
____________________________________________________________________
My gift is for the following purposes (you may check any number of boxes):
My gift is for transplant or therapy for another person, to be chosen based on generally accepted health
care standards.
My gift is for research and education. My preference, if any, is to give my body, organs, or tissues to the
following hospital, medical school, or physician:
Name ________________________________________________________
Address _______________________________________________________
________________________________________________________
I understand that I may need to contact the hospital, medical school, or physician before I die in order for them
to accept my body, organs or tissues after my death.
Page 10 of 14
Revised February 2008
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