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This Revocation of Anatomical Gift document may be used to revoke an anatomical gift made by the declarant in the past. Please choose proper State document for your needs as they are intended to be in full compliance with local statutes.
Docstoc Legal Agreements This Revocation of Anatomical Gift document is used to revoke an anatomical gift donation made by an individual located in Georgia. This form effectively revokes the gift and complies with states laws that allow for revocation. By completing this form, the individual provides the information necessary to revoke the anatomical gift and notifies any specified donee of the revocation. This document should be used by an individual that has previously made an anatomical gift and has changed his or her mind for any reason. ® DISCLAIMERS: ALL INFORMATION AND FORMS ARE PROVIDED “AS IS” WITHOUT ANY WARRANTY OF ANY KIND, EXPRESS, IMPLIED, OR OTHERWISE, INCLUDING AS TO THEIR LEGAL EFFECT AND COMPLETENESS. They are for general guidance and should be modified by you o r your attorney to meet your specific needs and the laws of your state. Use at your ow n risk. Docstoc, its employees or contractors who wrote or modified any form, are NOT providing legal or any other kind of advice and are not creating or entering into an Attorney -Client relationship. The information and forms are not a substitute for the advice of your own attorney. Use of this document and our service are deemed to be your acknowledgement and agreement to the following: The disclaimers and links on this page and the back page(s); our Terms of Service (http://www.docstoc.com/popterm.aspx?page_id=15), and read more here (http://www.docstoc.com/popterm.aspx?page_id=114) for additional disclaimers and more. You also agree that if you are not the person using the document and services that you will provide such person(s) who will be with these front and back disclaimer pages. This document is not approved, endorsed by, or affiliated with any State, or governmental or licensing entity. Entire document copyright © Docstoc®, Inc., 2010 - 2013. All Rights Reserved REVOCATION OF ANATOMICAL GIFT I, ______________________ [Instruction: Insert the Name of the Declarant], of _________________________ [Instruction: Insert the Address of Declarant], City of _________________________ [Instruction: Insert the City], County of _________________________ [Instruction: Insert the County], State of Georgia, executed an anatomical gift regarding my choices and decision in accordance with Uniform Anatomical Gift Act (“UAGA”), as codified at [STATUTE] Georgia Code, dated _____ [Month] __ [Date], 20 ____ [Instruction: Insert the date of execution of Anatomical Gift], do hereby revoke such gift pursuant to the [STATUTE], which provides that an anatomical gift may be revoked as follows: 1. A signed statement, 2. An oral statement made in the presence of two individuals, 3. Any form of communication during a terminal illness or injury addressed to a physician or surgeon, 4. The delivery of a signed statement to a specified donee to whom a document of gift had been delivered. This is my written revocation of my anatomical gift and is provided to all persons to whom I have provided a copy of my document of anatomical gift. DATED this ______ [Month] ____ [Date], 20___. Signature of Declarant : ____________________________________________ Printed Name of Declarant : ____________________________________________ Address of Declarant : ____________________________________________ Witness Signature #1 : _____________________________________________ Name : _____________________________________________ Address : _____________________________________________ Witness Signature #2 : _____________________________________________ Name : _____________________________________________ Address : _____________________________________________ © Copyright 2011 Docstoc, Inc. registered document proprietary, copy not 2
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