Donor Registry Enrollment Form (Optional) Page 4
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4Please select one of the following three options.
Option 1:
Upon my death, I make an anatomical gift of my organs, tissues, and eyes for any purpose
authorized by law.
Option 2:
Upon my death, I make an anatomical gift of the following specifi ed organ, tissues, or eyes:
ALL ORGANS, TISSUES AND EYES
ORGANS:
TISSUES:
HEART
EYES/CORNEAS
LIGAMENTS
LUNGS
HEART VALVES
VESSELS
LIVER
BONE
FASCIA
KIDNEYS
TENDONS
SKIN
PANCREAS
INTESTINE/SMALL BOWEL
For the following purposes authorized by law:
ALL PURPOSES
TRANSPLANTATION
THERAPY
RESEARCH
EDUCATION
Option 3:
Please take me out of the Organ Donor Registry.
Signature of Donor Registrant
Date Signed
Donor Registry Enrollment Form
Page Two of Two
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Parent category: Letters