Revocation of
Anatomical Gift
ocstoc Legal Agreements
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.
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Attorney Drafted
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 Minnesota, executed
an anatomical gift regarding my choices and decision in accordance with Revised Uniform
Anatomical Gift Act (“RUAGA”), as codified at Chapter 525A, Section 05 of Minnesota Code
dated _____ [Month] __ [Date], 20 ____ [Instruction: Insert the date of execution of
Anatomical Gift], do hereby revoke such gift pursuant to the Chapter 525A, Section 05 of
Minnesota Code, 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 : ____________________________________________
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Witness Signature #1 : _____________________________________________
Name : _____________________________________________
Address : _____________________________________________
Witness Signature #2 : _____________________________________________
Name : _____________________________________________
Address : _____________________________________________
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