Indiana Revocation of Anatomical Gift

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                             This Revocation of Anatomical Gift document is used to revoke an anatomical gift donation
                             made by an individual located in Indiana. 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.
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                         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 Indiana, executed an
anatomical gift regarding my choices and decision in accordance with Uniform Anatomical Gift
Act (“UAGA”), as codified at [STATUTE] Indiana 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                             : _____________________________________________

				
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Description: This Revocation of Anatomical Gift document is used to revoke an anatomical gift donation made by an individual located in Indiana. 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.
This document is also part of a package Essential Indiana Legal Documents 145 Documents Included