Communication

NYS Organ and Tissue Donor Registry Enrollment Form
( * required )Please
Prefix:(Dr., Fr., etc)Suffix:(Jr, Sr, II, etc)* Address:
* City:RochesterPhone:(716* Date of
* Height:5
5*
)feet21996inchesNew York State driver license or non-driver IDNY*146232223
*MaleX Female* Eye Color: Green
360215588* I offer the donation of:
All Organs, Tissues and Eyes
Limited Organs, Tissues and Eyes as specified below
Please CHECK the box of the organs and tissues that YOU WISH TO DONATE:
Bone and Connective Tissue
Corneas
Eyes
Heart (for Valves)
Heart with Connective Tissue
Kidneys
Liver/Illiac Vessels
Lungs
Pancreas
Skin
Small Intestine
Veins
* I wish to donate the organs and or tissues specified above for:
Transplant and Research
Transplant Only
Research Only
I wish to enroll in the New York State Donate Life Organ and Tissue Donor Registry maintained by the State Department of Health.
I understand that by enrolling in the registry I am giving legal consent to the donation of my organs tissues and eyes (as specified
above) in the event of my death. I authorize the State Department of Health to access this information as needed in administration of
the registry, and to share this information at or near the time of my death with federally regulated organ procurement organizations,
New York State licensed tissue and eye banks and entities formally approved by the Commissioner.Signature
Mail to:Date
New York State Donate Life Organ and Tissue Donor Registry
New York State Department of Health
875 Central Avenue
Albany, New York
3814869012320150425

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