Massachusetts Anatomical Gift Donation


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                             This Anatomical Gift Donation form can be used by individuals located in Massachusetts
                             wishing to donate their body or body parts upon death for scientific, educational or research
                             purposes. This form allows the individual to make the necessary arrangements before
                             death to facilitate the body donation process and gives any special instructions that the
                             individual desires to include. This document complies with the requirements of the Uniform
                             Anatomical Gift Act.

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                              ANATOMICAL GIFT DONATION

I, ____________________ [Instruction: Insert the name of the Donor], pursuant to
_________________ Massachusetts UNIFORM ANATOMICAL GIFT ACT (“the act”),
Section 16-27-11, 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]


    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)


2. Special Instructions or Special Limitations.


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   [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 Massachusetts UNIFORM ANATOMICAL GIFT ACT, Section 16-27-12:

   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 of medical or dental science, therapy or transplantation; or

       ii.      Any accredited medical or dental school, college or university for education,
                research, advancement of medical or dental science or therapy; or

       iii.     Any bank, storage facility or OPO for medical or dental education, research,
                advancement of medical or dental science, therapy or transplantation; or

       iv.      Any specified individual for therapy or transplantation needed by that individual.

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]

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[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]

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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