Fillable Advanced Directive (Page 7 of 7) in pdf

Advanced Directive Page 7

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ORGAN DONATION ADDENDUM

[Note: If you want to be an organ donor, you can attach this page to your living will or advance

directive. Sign it and have it witnessed.]

Upon my death, I wish to donate:

_____

Any needed organs, tissues, or eyes.

_____

Only the following organs, tissues, or eyes:

________________________________________________________

I authorize the use of my organs, tissues, or eyes:

_____

for transplantation;

_____

for therapy;

_____

for research;

_____

for medical education;

_____

for any purpose authorized by law.

I understand that before any vital organ, tissue, or eye may be removed for transplantation,

I must be pronounced dead. After death, I direct that all support measures be continued to

maintain the viability for transplantation of my organs, tissues, and eyes until organ, tissue and eye

recovery has been completed.

I understand that my estate will not be charged for any costs associated with my decision

to donate my organs, tissues, or eyes or the actual disposition of my organs, tissues, or eyes.

By signing below, I indicate that I am emotionally and mentally competent to make this

organ donation addendum and that I understand the purpose and effect of this document.

_____________________________

___________________________________

(Date)

(Signature of Declarant)

The declarant signed or acknowledged signing this organ donation addendum in my

presence and based upon my personal observation appears to be a competent individual.

____________________________________

___________________________________

(Witness)

(Signature of Two Witnesses)

Advanced Directive Page 7

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