Anatomical Gift Donation
ocstoc Legal Agreements
This Anatomical Gift Donation can be used by individuals wishing to donate
their body or body parts and to make necessary arrangements before death
that facilitates body donation for scientific, education, and/or research
purposes.
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Attorney Drafted
ANATOMICAL GIFT DONATION
I, ____________________ [Instruction: Insert the name of the Donor], pursuant to
_________________ IOWA REVISED UNIFORM ANATOMICAL GIFT ACT (“the act”),
Section 4-142C-4, hereinafter referred to as the “Donor” hereby make this “Anatomical Gift
Donation”, if medically acceptable, to take effect upon my death, to be used in such a manner as
may seem most desirable for educational, medical research and scientific purpose. The words
and marks below indicate my desires and instructions:
1. Description of Gift. [Instruction: Choose any one clause below as applicable]
I give any needed organs, body parts, tissue and/or my whole body.
[Instruction: Choose this clause if the whole body is donated by donor]
Or
I give only the following organs, body parts, or tissue specified below:
[Instruction: Choose this clause if specific body part/s to donate and insert “X” below
next to applicable organ(s)]
(___) Eye
(___) Bone
(___) Connective Tissue
(___) Skin
(___) Heart
(___) Kidney
(___) Liver
(___) Pancreas
(___) Others (Please Specify)
_____________________________________________________________________
____________________________________________________________________
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2. Special Instructions or Special Limitations:
___________________________________________________________________________
___________________________________________________________________________
[Instruction: Choose this clause if there is any special instruction or limitation made by
the donor regarding the anatomical donation]
3. Physician.
My physician ____________________ [Instruction: Insert the name of physician/ doctor]
is directed to honor my wishes expressed herein, and contact the concerned persons/donees
and arrange for the harvest of my body parts.
4. Purpose.
Pursuant to the IOWA REVISED UNIFORM ANATOMICAL GIFT ACT, Section 4-142C-
5:
Persons who may receive anatomical gifts; purpose of anatomical gift
a. The following may become donees of anatomical gifts for the purpose stated:
i. Any hospital, surgeon or physician for medical or dental education,
research, advancement or medical or dental science, therapy or
transplantation;
ii. Any accredited medical or dental school or college or university for
education, research, advancement of medical or dental science or therapy;
iii. An eye bank or tissue bank;
iv. Any bank or storage facility for medical or dental education, research,
advancement of medical or dental science, therapy or transplantation; or
v. Any specified individual for therapy or transplantation needed by him.
vi. For any other purpose or to any other individual an outlined by Section 4-
142C-5 of the Act.
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IN WITNESS WHEREOF, I, __________________ [Instruction: Insert the name of Donor]
the “Donor”, and the following witnesses, have signed this Anatomical Gift Donation in the
presence of each other.
____ [Month] ___ [Date] 20__.
_________________________________
[Instruction: Insert signature of Donor]
____________________________________________
[Instruction: Insert printed/typed name of Donor]
________________________________
[Instruction: Insert address of Donor]WITNESSES:
____________________________________
[Instruction: Insert signature of Witness#1]
_______________________________________________
[Instruction: Insert printed/typed name of Witness#1]
___________________________________
[Instruction: Insert address of Witness#1]
____________________________________
[Instruction: Insert signature of Witness#2]
_______________________________________________
[Instruction: Insert printed/typed name of Witness#2]
___________________________________
[Instruction: Insert address of Witness#2]
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ACKNOWLEDGEMENT
The foregoing Anatomical Gift Donation was acknowledged before me this ___________ (date)
by ____________________________________________ (name of person who acknowledged).
Signature of Person Taking Acknowledgement: ________________________________
Title or Rank: ___________________________________________________________
Serial Number, if any: _____________________________________________________
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Note: Carefully read and follow the Instructions and Comments contained in this document for
your customization to suit your specific circumstances and requirements. You will want to
delete the Instructions and Comments from open bracket (“[“) to close bracket (“]”) after
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