State Of Arizona Durable Health Care Power Of Attorney Page 3
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51. What organs/tissues I choose to donate: (Select a or b below)
a. Whole body
b. Any needed parts or organs:
c. These parts or organs only:
1)
2)
3)
2. What purposes I donate organs/tissue for: (Select a, b, or c below)
a. Any legally authorized purpose (transplantation, therapy, medical and dental evaluation,
education or research, and/or advancement of medical and dental science).
b. Transplant or therapeutic purposes only.
c. Research Only
d. Other:
3. Which organization or person I want my parts or organs to go to:
a. I have already signed a written agreement or donor card regarding organ and tissue
donation with the following individual or institution:(name)
b. I would like my tissues or organs to go to the following individual or institution:
c. I authorize my representative to make this decision.
7. Funeral and Burial Disposition (Optional):
My agent has authority to carry out all matters relating to my funeral and burial disposition wishes in accordance with
this power of attorney, which is effective upon my death. My wishes are reflected below:
NOTE: If you choose whole body donation, cremation is the only burial disposition available.
Place your initials by those choices you wish to select.
_ Upon my death, I direct my body to be buried. (As opposed to cremated)
Upon my death, I direct my body to be buried in
. (Optional directive)
Upon my death, I direct my body to be cremated.
Upon my death, I direct my body to be cremated with my ashes to be
. (Optional directive)
My agent will make all funeral and burial disposition decisions. (Optional directive)
8. About a Living Will
NOTE: If you have a Living Will and a Durable Health Care Power of Attorney, you must attach the Living Will to this
form. A Living Will form is available on the Attorney General (AG) web site. Initial or put a check mark by box A or B.
_ A. I have SIGNED AND ATTACHED a completed Living Will in addition to this Durable Health Care
Power of Attorney to state decisions I have made about end of life health care if I am unable to
communicate
or make my own decisions at that time.
B. I have NOT SIGNED a Living Will.
Office of the Attorney General of Arizona, Mark Brnovich
Sec. 3: Page 3 of 5
Updated 06/16
Life Care Planning Packet: Durable Health Care Power of Attorney
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