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 parts

(b) ______only the following organs or parts

________________________________________________________________

for the purposes of transplantation, therapy, medical research or education,

(c) _____my body for anatomical study if needed.

Limitations or

special wishes, if any: ______________________________________________

This is a legal document under the Uniform Anatomical Gift Act or similar laws.