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OTHER NAMES Organ Donor Form

What is an Organ Donation Form?

Use this form to state your intent to donate organs and tissues. You may also instruct that your donation be used for such purposes as transplantation, education, or research.

When to use an Organ Donation Form:

You want written documentation to help assure that your wishes are honored.
You want to specify which organs may, or may not, be donated.
You want to specify a certain person to receive your organ donation.

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______ any needed organs, tissues, or parts except my: .______ any needed organs, tissues, or parts except my: ________________________.______ the following organs, tissues, or parts only: .______ the following organs, tissues, or parts only: ____________________________.I, the undersigned, this _____ day of ____________________, _____, desiring that my organs, tissues, or parts be made available after my demise for:I, the undersigned, this _____ day of ___________________, _____, desiring that my organs, tissues, or parts except my be made available after my demise for:I, the undersigned, this _____ day of ___________________, _____, desiring that my , , (Address)._____________________________________ (Address).any donee authorized by law any needed organs, tissues, or parts for any purpose authorized by law, including transplantation, therapy, research, or education.any needed organs, tissues, or parts except my , for any purpose authorized by law, including transplantation, therapy, research, or education. for any purpose authorized by law, including transplantation, therapy, research, or education.

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for any purpose authorized by law, including transplantation, therapy, research, or education.

Limitations or special wishes, if any:

I revoke any previous document or writing where I donated my organs, tissues, or parts to take effect on my death. I intend for this document to direct the removal and use of my organs, tissues, or parts at my death.I amend any previous document or writing where I donated my organs, tissues, or parts to take effect on my death. To the extent this document is inconsistent with or more complete than any previously completed form, I intend for this document to amend or supplement the previous document.I hereby revoke any previous document or writing where I indicated my refusal to donate my organs, tissues, or parts after my death.

If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.

I witnessed that this document was signed in my presence by the Donor and certify that the Donor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:

I witnessed that this document was signed in my presence by the Donor. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:

in accordance with Indiana's Anatomical Gift Act

I witnessed that this document was signed in my presence by at the direction of and in the presence of the Donor who was physically unable to sign. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:

I witnessed that this document was signed in my presence by at the direction of and in the presence of the Donor who was physically unable to sign and certify that the Donor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:

WeI and Parent(s) Guardian(s) and sign this document in the presence of the Donor and two additional witnesses who sign belowParent Signature: __________________________________________Guardian Signature: __________________________________________

I witnessed that this document was signed in my presence by the Donor. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:

I witnessed that this document was signed in my presence by the Donor and the Donor's I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:

I witnessed that this document was signed in my presence by the Donor and the Donor's and certify that the Donor was of sound mind and memory and free of any undue influence and knew the objects of his bounty and affection. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:

WeI and Parent(s) Guardian(s) Parent Signature: __________________________________________Guardian Signature: __________________________________________

parents. parent. guardians. guardian. parents parent guardians guardian Parent Guardian Parent Signature: ___________________________________Guardian Signature: ___________________________________Signed by the Donor and the following two witnesses in the presence of each other:Signature of the Donor's Representative who signs on the Donor's behalf at the direction of and in the presence of the Donor who is physically unable to sign and in the presence of two witnesses:Donor Signature: __________________________________Representative Signature: __________________________________

WARNING: One of the witnesses should be a parent or guardian who also consents to the donation.