Alaska Statutes.
Title 13. Decedents' Estates, Guardianships, Transfers, and Trusts.
Chapter 52. Health Care Decisions Act
Section 190. Optional Form For Anatomical Gift By Another Person.
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AS 13.52.190. Optional Form For Anatomical Gift By Another Person.

GUARDIAN, AGENT, OR SURROGATE

ANATOMICAL GIFT BY NEXT OF KIN, 

Under AS 13.52.170 - 13.52.280, I make this anatomical gift from the   

body of                                                                

____________________________________________________________________   

(name of decedent)                                                     

who died on                                                            

____________________________________________________________________   

 (date)                                                                 

at                                                                     

____________________________________________________________________   

 (place) (city)                                                         

in                                                                     

____________________________________________________________________  

 (state)                                                                

The marks in the appropriate squares and the words filled into the     

blanks below indicate my relationship to the decedent and my wishes    

respecting the gift.                                                   

I survive the decedent as [ ] spouse; [ ] adult son or daughter;

[ ] parent; [ ] adult brother or sister; [ ] grandparent;

or I am the decedent's [ ] agent under AS 13.52

or [ ] surrogate under AS 13.52.

I hereby give (check boxes applicable):                                

[ ] any needed organs, tissues, or parts;

[ ] the following organs, tissues, or parts only:

__________________________________________________________________ ; 

[ ] the following purposes only:

__________________________________________________________________ .


____________________________________________________________________

 (date) (signature of survivor)


____________________________________________________________________


____________________________________________________________________

 (address of survivor)

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