organ donation form english legal printable

1. ORGAN DONATION FORM
I ________________________________ of ___________________________ City________________________
State__________________________________ Zip code __________________________________
Give my body, organs tissues or parts as directed below. This anatomical gift takes effect upon my death.
I give: (initial one of 4 options )
______________ Full body
______________ any needed organs, tissues, or parts
______________any needed organs, tissues, or parts except my :_____________________________________
______________the following organs, tissues, part only:____________________________________________
I give my organs, tissues, or parts indicated above to be used for : (initial one of the two options)
_____ any purpose autorised by law.
______the following purposes only: (initial all that apply)
_________ transplant
__________research
__________terapy
__________education
limitations or special wishes, if any:_______________________________________________________________
If any provisions of this document is held to be invalid, such invalidity shall not affect the other provisions which can
be given effect without the invalid provisions , and to this end the directions in this document are severable.
Any older donation forms are void.
Signature__________________________________ Date ___________________________
____________________________________________
Notary seal and signature