Advance Directives Combined Form - Ct Attorney General Page 3
ADVERTISEMENT
1
2
3
4DOCUMENT OF ANATOMICAL GIFT
I make no anatomical gift at this time.
_____
(Initial here)
I hereby make this anatomical gift, if medically acceptable,
_____ (
Initial here)
to take effect upon my death
I give: (check one)
____ (1) any needed organs or parts
____ (2) only the following organs or parts:
________________________________________________________________________
________________________________________________________________________
to be donated for: (check one)
___ (1) any of the purposes stated in subsection (a) of section 19a-279f of the general statutes
___ (2) these limited purposes _______________________________________.
DESIGNATION OF A CONSERVATOR OF THE PERSON
I choose not to designate a person to be appointed as my conservator. ______
(Initial here)
If a conservator of my person should need to be appointed, I designate
_______________________________________________, be appointed my conservator.
If this person is unwilling or unable to serve as my conservator of my person, I designate
________________________________________________ be appointed my conservator.
No bond shall be required of either of them in any jurisdiction.
These requests, appointments, and designations are made after careful reflection, while I
am of sound mind. Any party receiving a duly executed copy or facsimile of this
document may rely upon it unless such party has received actual notice of my revocation
of it.
x
______________________________________L.S.
Date _______________, 20____
WITNESSES' STATEMENTS
This document was signed in our presence by _____________________________ the author of
this document, who appeared to be eighteen years of age or older, of sound mind and able to
understand the nature and consequences of health care decisions at the time this document was
signed. The author appeared to be under no improper influence. We have subscribed this document
in the author's presence and at the author's request and in the presence of each other.
x__________________________
x___________________________
(Witness)
(Witness)
x__________________________
x___________________________
(Number and Street)
(Number and Street)
x__________________________
x___________________________
(City, State and Zip Code)
(City, State and Zip Code)
OPTIONAL FORM
3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Ct-3-att - T New York State Department Of Taxation And Finance Schedules B, C And D - Attachment To Form Ct-3 General Business Corporation Franchise Tax Return - 1998
Financial
Form Ct-3-att - Schedules B, C, And D - Attachment To Form Ct-3 - General Business Corporation Franchise Tax Return - 2012
Financial
Form Ct-3-att - Schedules B, C, And D - Attachment To Form Ct-3 - General Business Corporation Franchise Tax Return - 2014
Financial
Related Categories
Parent category: Medical