Johnson Legal PLLC
operating as Bluegrass Cornerstone
19 Fairway Drive · Elizabethtown, KY 42701 · (502) 230-1620 · johnsonbluegrasslaw.com
Kentucky Bar № 101547

ANATOMICAL GIFT DESIGNATION
(Kentucky Revised Uniform Anatomical Gift Act, KRS 311.1911 to 311.1959)
KENTUCKY - Johnson Legal PLLC d/b/a Bluegrass Cornerstone
This document is a record of an anatomical gift made during the life of the donor by a signed record under KRS 311.1917(2).

DONOR (the individual making this anatomical gift)

Name: Margaret Ann Thompson
Date of birth: 1948-03-12
Address: 482 Larkspur Lane, Elizabethtown, KY 42701
Telephone: (270) 555-0142

I, Margaret Ann Thompson, am the donor identified above. I make the anatomical gift stated in this document voluntarily.

DONOR ELIGIBILITY (KRS 311.1915)

I attest that I am eligible to make an anatomical gift under KRS 311.1915(1): I am at least eighteen (18) years of age; or I am an emancipated minor; or I am at least sixteen (16) years of age and authorized under state law to apply for a driver license. My date of birth is stated above.

THE GIFT (KRS 311.1915 and KRS 311.1917(2))

I, Margaret Ann Thompson, make an anatomical gift of:

any needed organ, eye, or tissue of my body - each a part as defined in KRS 311.1911(18). This is the broadest gift of parts; it does not give my whole body.

This gift is made by a signed record under KRS 311.1917(2). An anatomical gift takes effect only after the death of the donor (KRS 311.1911(3)).

PURPOSES OF THE GIFT (KRS 311.1915 and KRS 311.1929)

I authorize the following purposes: transplantation, therapy, research, and education. These are purposes authorized by KRS 311.1915. If more than one purpose is set forth without priority, KRS 311.1929(4) directs that the gift be used for transplantation or therapy if suitable, and otherwise for research or education.

RECIPIENT (KRS 311.1929)

I do not name a specific recipient in this document. The gift passes under KRS 311.1929 - generally to the appropriate eye bank, tissue bank, or organ procurement organization for the kind of part given.

PROTECTION OF MY MEDICAL CARE (KRS 311.1917(5))

The making of an anatomical gift shall not under any circumstances be construed to authorize or direct the denial of health care or hydration and nourishment when the withholding or withdrawal of health care or hydration and nourishment will result in or hasten death. In plain language: being a donor never reduces the medical care I receive. My medical team owes me the same effort to preserve my life whether or not I am a donor, and this gift takes effect only after the death of the donor.

EFFECT OF MY DECISION ON OTHER PERSONS (KRS 311.1923)

Under KRS 311.1923(1), except as otherwise provided in KRS 311.1923(7) and subject to KRS 311.1923(6), in the absence of an express, contrary indication by the donor, a person other than the donor is barred from making, amending, or revoking this gift once the donor has made it. In plain language: this gift is my decision. After my death my family may not revoke or override it. I am making this decision now so that the people who care about me are not asked to make it for me later. (If the donor is an unemancipated minor, KRS 311.1923(7) preserves the ability of a parent who is reasonably available to revoke or amend the gift after the death of the donor.)

THIS DOCUMENT MAKES A GIFT - IT IS NOT A REFUSAL (KRS 311.1921)

This document MAKES an anatomical gift. It is not a refusal. A refusal is a separate instrument under KRS 311.1921 by which an individual may expressly bar other persons from making an anatomical gift of the body or part of the individual. If I ever decide that I do not want to be a donor at all, the correct steps are to revoke this gift (see the next section) and, for the strongest protection against any donation, to execute a separate refusal under KRS 311.1921.

AMENDMENT AND REVOCATION - FOR YOUR RECORDS (KRS 311.1919)

I may amend or revoke this gift at any time before my death. Under KRS 311.1919 the available paths include: (a) a new record signed by me - or, if I am physically unable to sign, signed by another individual at my direction and witnessed by at least two adults, at least one of whom is a disinterested witness, with the record stating that it has been signed and witnessed as provided in KRS 311.1919(2); (b) a later-executed document of gift that amends or revokes this gift either expressly or by inconsistency; (c) destruction or cancellation of this document, or the portion of it used to make the gift, with the intent to revoke the gift; and (d) during a terminal illness or injury, any form of communication addressed to at least two adults, at least one of whom is a disinterested witness.

COORDINATION WITH DRIVER LICENSE DESIGNATION (KRS 311.1917(1)(a))

The donor also has, or intends to add, a donor designation on a Kentucky driver license or identification card. A statement or symbol on a driver license or identification card is itself a valid way to make an anatomical gift (KRS 311.1917(1)(a)). Having BOTH a license designation AND this signed record is intentional: each independently establishes the gift, and under KRS 311.1917(3) revocation, suspension, expiration, or cancellation of the license does not invalidate the gift.

MANNER OF SIGNING (KRS 311.1917(2))

The donor is making this gift by a record signed by the donor personally under KRS 311.1917(2). Witnesses are not required by KRS 311.1917(2) when the donor signs the record personally; witness lines are provided below as a customary best practice to assist later verification of this record.

SIGNATURE (KRS 311.1917(2))

Signature of donor: ____________________________________________
Printed name of donor: Margaret Ann Thompson
Date signed: ___________________________

WITNESSES (customary - not required by KRS 311.1917(2) when the donor signs personally)

Witness 1 signature: ____________________________________________
Witness 1 printed name: Carol Hayes
Date: ___________________________

Witness 2 signature: ____________________________________________
Witness 2 printed name: Robert Hayes
Date: ___________________________

Document prepared by:
Johnson Legal PLLC, operating as Bluegrass Cornerstone (registered Kentucky DBA)
Attorney of record: Durward Elton Johnson, Kentucky Bar # 101547. Prepared from donor input as an anatomical gift designation under the Kentucky Revised Uniform Anatomical Gift Act, KRS 311.1911 to 311.1959; reviewed and approved by a Kentucky-licensed attorney before delivery per KBA Ethics Opinion E-457.

Execution Instructions - Anatomical Gift Designation (KRS 311.1911 to 311.1959)

Your anatomical gift designation has been drafted from your intake answers as a signed record under KRS 311.1917(2). If you can sign personally, the law requires only your signature - witnesses are customary but not required, and no notary is required by the Act. If you are physically unable to sign, a different rule applies: another individual may sign at your direction, and the record MUST be witnessed by at least two adults, at least one of whom is a disinterested witness - your document includes the required witness affidavit if you indicated this at intake.

  1. Read the entire designation carefully. Confirm the gift scope (what you are giving), the purposes (or the statutory default if you elected none), and any named recipient are exactly what you intend.
  2. If you can sign personally: sign and date the designation in the SIGNATURE section. Your signature makes the gift under KRS 311.1917(2). Witness lines are provided as a customary best practice - two adult witnesses help later verification - but witnesses are not required by the Act when you sign personally.
  3. If you are physically unable to sign: another individual may sign at your direction, in your presence. The record MUST then be witnessed by at least two (2) adults, at least one (1) of whom is a disinterested witness - generally a person who is NOT your spouse, child, parent, sibling, grandchild, grandparent, or guardian, NOT an adult who exhibited special care and concern for you, and NOT a person to which the gift could pass under KRS 311.1929 (see KRS 311.1911(5)). All witnesses sign at your request. Your document includes the required affidavit language if you indicated this path at intake.
  4. No notary is required by KRS 311.1911 to 311.1959 for a signed-record gift. If a hospital, registry, or program voluntarily asks for a notarized record, any Kentucky notary public may acknowledge the signature - this is optional.
  5. Keep the original signed record with your other estate-planning documents and give a copy to a person who would know your wishes - typically the health care surrogate named in your health care power of attorney, or a close family member. Telling your family now matters: under KRS 311.1923 your documented decision has preclusive effect, and families who already know the decision are not asked to make it in the hospital. Also consider the driver-license designation (KRS 311.1917(1)(a)) and the Kentucky donor registry - each path independently establishes the gift, and a license designation survives license revocation, suspension, expiration, or cancellation (KRS 311.1917(3)). The record itself need not be delivered to anyone during your lifetime to be effective.
  6. If you elected whole-body donation: most whole-body (anatomical study) programs - typically operated by medical schools - require pre-registration and acceptance by the receiving institution under the rules of the program. Contact the intended program directly to complete its enrollment requirements, and tell the reviewing attorney which program you intend so it can be named in the RECIPIENT section.
  7. You may amend or revoke this gift at any time before your death (KRS 311.1919): sign a new record (if someone signs at your direction because you are physically unable to sign, the record must be witnessed by at least two adults, at least one of whom is a disinterested witness, and must state that it has been signed and witnessed as provided in KRS 311.1919(2)); execute a later document of gift that amends or revokes this one expressly or by inconsistency; destroy or cancel this document with the intent to revoke; or, during a terminal illness or injury, communicate the change to at least two adults, at least one of whom is a disinterested witness. If you ever decide you do not want to be a donor at all, ask about a separate refusal under KRS 311.1921 - a refusal is a distinct instrument that bars others from making a gift of your body or part.

Bluegrass Cornerstone is a service of Johnson Legal PLLC, a Kentucky law firm. This document was prepared from your intake answers as an anatomical gift designation under the Kentucky Revised Uniform Anatomical Gift Act, KRS 311.1911 to 311.1959, and was reviewed and approved by a Kentucky-licensed attorney with Johnson Legal PLLC before delivery, per KBA Ethics Opinion E-457. Attorney of record: Durward Elton Johnson, Kentucky Bar # 101547. There is no fee for this document. For questions, email support@bluegrasscornerstone.com - your message will be routed to the reviewing attorney.