Mississippi 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 Mississippi. 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 Mississippi, executed
an anatomical gift regarding my choices and decision in accordance with Uniform Anatomical
Gift Act (“UAGA”), as codified at [STATUTE] Mississippi 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

4. The delivery of a signed statement to a specified donee to whom a document of gift had been

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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