Supplemental Estate Planning Intake Form Single Person Page 4

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Option 2:
Upon my death, I make an anatomical gift of the following specified
organ, tissues, or eyes:
ALL ORGANS, TISSUES AND EYES
ORGANS:
TISSUES:
HEART
EYES/CORNEAS
LUNGS
LIGAMENTS
LIVER
HEART VALVES
KIDNEYS
VESSELS
PANCREAS
BONE
INTESTINE/SMALL BOWEL
FASCIA
TENDONS
SKIN
For the following purposes authorized by law:
ALL PURPOSES
TRANSPLANTATION
THERAPY
RESEARCH
EDUCATION
Supplemental Estate Planning Intake Form – Single Person – Version 14.1
Page 4 of 4

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