Durable Power Of Attorney For Health Care Page 15
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15DONATION FORM
fold and mail to:
Gift of Life Society of Michigan● 2203 Platt Road ● Ann Arbor, Mi 48104
Questions? Please feel free to call: 1-800-482-4881 or 1-800-247-7250
Uniform Donor Card
of
Print or type name of donor)
(
In the hope that I may help others, I hereby make this anatomical gift if medically acceptable, to take
effect upon my death. The words and marks below indicate my desires.
I give (a)
any needed organs or physical parts
(b)
only the following organs or physical parts:
(Specify the organ (s) or physical parts (s)
For the purposes 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 at least 1 witness in the presence of each other:
Signature of donor
Date of birth of donor
Date Signed
Donor’s complete address (city, state, zip code)
Witness
Witness
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