2006 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.
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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