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DONATION PURSUANT
TO THE MISSISSIPPI ANATOMICAL GIFT LAW In the event of my death, I donate
the following part(s) of my body for the purposes identified in Mississippi
Code Annotated 41-39-31 to 41-39-51.
Please Complete All Applicable
Sections
Select
County:
Your Name:
Address:
City:
State:
Zip:
Phone:
Email:
Date of
Birth:
U.S. Citizen? Yes
No
Other Names:
Are you known by any other names.
Gender:
Male
Female
Name of Spouse:
Provide the Full name of your spouse.
m
Power of Attorney
TISSUE:
Eye
Bone
and connective tissue
Skin
Heart
Other:
ORGAN:
Heart
Kidney
Liver
Lungs
pancreas
Other:
h
Optional Items
Describe Other Provisions desired:
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