ORGAN DONATION AUTHORIZATION DIRECTIVE
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Effective Date: ________________________________________________________
Place: _________________________________________________________________

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1. Signatory
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This document is made on ____________________ (____________________) by:

Donor
Individual
Full Legal Name: _______________________________________________________
SSN / ID: ______________________________________________________________
Doc Series: ____________________________________________________________
Address: _______________________________________________________________
         _______________________________________________________________

2. SUBJECT-MATTER SCHEDULE & SPECIFICATIONS
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Organs & Tissues to Donate: ____________________________________________
Permitted Purposes (Transplant, Research):
    ____________________________________________________________________
Limitations: ___________________________________________________________
Donor Registry Number: _________________________________________________

3. EXECUTION & SIGNATURES
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Donor

Signature: _____________________________________________________________

Full Legal Name: _______________________________________________________
Date: __________________________________________________________________