Living Will, Designation Of Health Care Surrogate, Uniform Donor Forms Page 3
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3Uniform Donor Form
The undersigned hereby makes this anatomical gift, if medically acceptable, to take effect on death.
The words and marks below indicate my desires (select only one of the options below):
I give:
(a) _____ any needed organs or parts
(b) _____ only the following organs or parts for the purpose of transplantation, therapy, medical
research, or education:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
(c) _____ my body for anatomical study if needed. Limitations or special wishes, if any:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Signed by the donor and the following witnesses in the presence of each other:
Donor’s Signature ___________________________________ Donor’s Date of Birth _____________
Date Signed ______________ City and State ____________________________________________
Witness _____________________________
Witness _____________________________
Street Address ________________________
Street Address ________________________
City __________________ State_______
City __________________ State_______
You can use this form to indicate your choice to be an organ donor. Or you can designate it on your
driver’s license or state identification card (at your nearest driver’s license office).
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