Advance Directive Template (Page 4 of 4) in pdf

_______ I do not wish to donate any of my organs or tissues.

_______ I want to donate all of my organs and tissues.

_______ I only want to donate these organs and tissues:________________________

_______ Other wishes:__________________________________________________

Autopsy

_______ I do not want any autopsy.

_______ I agree to an autopsy if my doctors wish it.

_______ Other wishes:__________________________________________________

If you wish to say more about any of the above choices, or if you have any other

statements to make about your medical care, you may do so on a separate sheet of paper.

If you do so, put here the number of pages you are adding:____

PART 4. SIGNATURE

You and two witnesses must sign this document for it to be legal.

A. Your Signature

By my signature below I show that I understand the purpose and the effect of this

document.

NAME________________________________________________________________________DATE____________________

___________________________________________________________________________

ADDRESS

B. Your Witnesses’ Signature

I believe the person who has signed this advance directive to be of sound mind, that

he/she signed or acknowledged this advance directive in my presence, and that he/she

appears not be acting under pressure, duress, fraud or undue influence. I am not

related to the person making this advance directive by blood, marriage or adoption,

nor, to the best of my knowledge am I named in his/her will. I am not the person

appointed in this advance directive. I am not a health care provider or an employee

of health care provider who is now, or ahs been in the past, responsible for the care of

the person making this advance directive.

Witness#1

NAME_______________________________________________________________________DATE____________________

ADDRES_______________________________________________________________________________________________

Witness#2

NAME_______________________________________________________________________DATE____________________

ADDRESS_____________________________________________________________________________________________

Advance Directive Template Page 4