ASDAL/od-form

ORGAN DONOR FORM

Instructions:

This form is a legal document under the following Uniform Anatomical
Gift Act and similar laws.

Sign this form and have it witnessed by two persons, preferably your
next of kin of legal age.

If you are under 18, a parent or a guardian must sign. Please type or
print your information.

Donor's Full Name: ____________________________________________________
Mailing Address: ______________________________________________________

City: _________________________________________________
State: __________ Zip: __________

Today's Date: _________________ Date of Birth: ____________________
Social Security # (optional): _____ - _____ - _____
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 any needed organs and tissues only to organ / tissues listed below:

__________________________ __________________________
__________________________ __________________________
__________________________ __________________________
__________________________ __________________________
__________________________ __________________________

Donor Signature: ___________________________________________
Witness Signature: __________________________________________
Witness Signature: __________________________________________
Parent / Guardian Signature: __________________________________