I, Jay H. Davison, _______________,
Covina, California 917__ state and affirm that I
am more than eighteen (18) years old and that I
am of sound mind. I further state and affirm
that I am not now taking any medication or
suffering from any infirmity that would affect
my judgment generally or specifically pertaining
to the matters in this Organ Donation
Statement.
I hereby make an anatomical gift, to take
effect only upon my death, as follows:
Eyes, or any part of them, skin, bone
and/or bones, any organ, teeth, or any body part
not specifically named herein, shall be given to
Loma Linda University and/or Hospital and/or
Medical Center or its assignees. This gift may
be used for assisting any living person in
having a more healthful and enjoyable life. My
donation gift may not be used for research or
education of any kind.
The gift herein is made after careful
thought and consideration of the meaning and
effect of such gifts and with the desire that it
be carried out as fully and completely as
reasonably possible. Further, it is my wish that
my relatives, friends, and physicians honor my
desires and provide reasonable assistance in
carrying out the meaning and intent of this
Organ Donation Statement.
I have not made any prior donation
statements. This donation is invalid if the
donee and/or its assignee shall charge, directly
or indirectly, me, my estate, or heirs, any
money or consideration of any kind, for
acceptance of this donation.
Dated: November , 2001
______________________________
Signature of Jay H.
Davison
Witnesses
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(Witness Signature)
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Print Name
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Address
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Tel. No.
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Date
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(Witness Signature)
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Print Name
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Address
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Tel. No.
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Date
