Declaration of My Intent Regarding Recognizing the persuasion that may be exercised on my agent, or other relatives, if I am deemed to be a candidate for organ/tissue donation, I, ________________________________, want to declare here my intent regarding organ/tissue donation upon my death. (Initial your selection.) ____ I refuse to make an anatomical gift of any organ or tissue under any circumstances. ____ I refuse to make an anatomical gift of any vascularized organ
(vital organ). I do not want any vascularized
organ (vital organ) taken for transplantation or for any other purpose. My agent, appointed by this DPAHC, may make all
other decisions regarding anatomical gifts after my agent is certain that I am dead. (This option is recommended if you do not
consider brain death to be a reliable determination of death. More information on this issue is available from
Illinois Right to Life Committee.) ____ I authorize an anatomical gift of any organ or tissue, but at the discretion of my agent, as appointed by this DPAHC. ____ I authorize an anatomical gift of only the following organs or
tissue: __________________ ____ I authorize an anatomical gift of any organ or tissue based on
my irrevocable intent. (This option is
consistent with registration in the Organ/Tissue Donor Registry – offered to you each
time you renew your driver’s license.) Signature _____________________________________ Date _______________________ Witness _____________________________________ Date _______________________ Witness _____________________________________ Date _______________________
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