ORGAN DONATION FORM

I, Dorian Mayhew Rothschild, of 60 Arthur St., San Rafael, California 94901, give my organs, tissues, or parts as directed below. This Anatomical Gift will take effect upon my death. I give: (initial one of three options) ______ any needed organs, tissues, or parts. ______ any needed organs, tissues, or parts except my: brain. ______ the following organs, tissues, or parts only: ____________________________. I give my organs, tissues, or parts indicated above to be used for: (initial one of the two options) ______ any purpose authorized by law. ______ the following purposes only: (initial all that apply) ______ transplantation______ research ______ therapy______ education Limitations or special wishes, if any: None. My organs, tissues, or parts should be given to: The Buck Institute 35 Palm Circle Dr. Novato, California 95422 If the above cannot or does not accept my organs, tissues, or parts I desire that: (initial one) ______ my organs, tissues, or parts be given to any authorized donee. ______ my organs, tissues, or parts not be donated at my death. If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.

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Donor Signature:

__________________________________________ Dorian Mayhew Rothschild ___________________ May 21, 1957

Date Signed: Donor's Date of Birth:

I witnessed that this document was signed in my presence by the Donor. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness:

Witness Signature:

__________________________________________ Ryan G. Jagger

Witness Signature:

__________________________________________ Thomas R. Dillon

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