New Jersey Instruction Directive Template (Page 4 of 5) in pdf

medical research and education. This section allows you to indicate your desire to make an anatomical gift and if

so, to provide instructions for any limitations or special uses.)

Initial the statements which express your wishes:

1. ______ I wish to make the following anatomical gift to take effect upon my death:

A. ______ any needed organs or body parts

B. ______ only the following organs or parts

______________________________________________________________________________

for the purposes of transplantation, therapy, medical research or education, or

C. ______ my body for anatomical study, if needed.

D. ______ special limitations, if any:

______________________________________________________________________________

If you wish to provide additional instructions, such as indicating your preference that your organs be given to a

specific person or institution, or be used for a specific purpose, please do so in the space provided below.

___________________________________________________________________________________________

2. ______ I do not wish to make an anatomical gift upon my death.

Part Two: Signature andWitnesses

G) COPIES: The original or a copy of this document has been given to the following people (NOTE: It is

important that you provide a family member, friend or your physician with a copy of your directive.):

1. name ___________________________________

address _________________________________

city ________________________ state _______ telephone __________________________

2. name ___________________________________

address _________________________________

city ________________________ state _______ telephone __________________________

Additional sheets may be added if necessary.

America Living Will Registry, LLC • 2814 Beach Boulevard South • St. Petersburg, FL 33707 • 866-305-ALWR • •

New Jersey Instruction Directive Template Page 4