2005 Alaska Statutes
Title 13 DECEDENTS' ESTATES, GUARDIANSHIPS, TRANSFERS, AND TRUSTS
Chapter 13.52. HEALTH CARE DECISIONS ACT
Sec. 13.52.190. Optional form for anatomical gift by another person.

ANATOMICAL GIFT BY NEXT OF KIN,

GUARDIAN, AGENT, OR SURROGATE

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)