Form Cad-009 - Living Will Declaration - Meridian Health Page 2

MERIDIAN HEALTH

JSUMC • OMC • RMC

LIVING WILL DECLARATION

CAD-009 (8-10)S PAGE 2 OF 2

*CL0002*

Organ/Tissue Donation can save

ORGAN DONATION: I hereby make this anatomical gift to take effect upon

my death:

lives, preserve sight and improve

function. You may limit your

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I give

any needed organs or parts

anatomical gift (cornea, kidney, etc.)

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the following organs or parts _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

or potentially help numerous people.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

to be used for transplantation or otherwise for the direct care and treatment of

another person.

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I do not give permission for organ donation.

Signed: ________________________________________________________________

AUTOPSY CONSENT:

The autopsy is valuable tool

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I agree to the performance of an autopsy in the event that my physician(s) feel

for expanding our understanding

that it would further medical knowledge or improve medical care.

of disease, its diagnosis and

treatment.

Limitation(s) (if any) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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I do not give permission for an autopsy.

Signed: ________________________________________________________________

Organ donation and autopsy are surgical procedures

which do not result in unusual disfigurement of the body

.

Signed: ______________________________________ Date: ____________________

Sign and date here in the presence of

two adult witnesses, who should also

Witness: ___________________________ Witness: ___________________________

sign, or before a Notary Public.

Date:____________ Time:______AM/PM Date:____________ Time:______AM/PM

Neither adult witness can

be your designated health care proxy

Address: ___________________________ Address: __________________________

or alternate proxy.

___________________________________ ___________________________________

Keep the signed original with your

Reviewed on: It is recommended that

personal papers at home. Give signed

you review your Declaration annually,

copies to doctors, family, proxy, and

initial and date it to show it still express-

to you hospital should you require

es your intent.

medical treatment.

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Adapted with permission of Choice in Dying,

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formerly Concern for Dying / Society for the Right

to Die, 250 West 57th St. / New York, NY 10101

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