Donor Registry Enrollment - Ohio Department Of Public Safety Bureau Of Motor Vehicles

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OHIO DEPARTMENT OF PUBLIC SAFETY
BUREAU OF MOTOR VEHICLES
DONOR REGISTRY ENROLLMENT
To register, please complete and mail this enrollment form to:
Ohio Bureau of Motor Vehicles
Attn: Records Request
P.O. BOX 16583
Columbus, OH 43216-6583
PLEASE PRINT
LAST NAME
FIRST
MIDDLE
MAILING ADDRESS
CITY
STATE
ZIP
PHONE
DATE OF BIRTH
STATE OF OHIO DL/ID CARD OR SSN
)
-
/
/
(
DONOR REGISTRY ENROLLMENT OPTIONS
OPTION 1
Upon my death, I make an anatomical gift of my organs, tissues and eyes for any purpose authorized by law.
OPTION 2
Upon my death, I make an anatomical gift of the following organs, tissues, and/or eyes selected below:
ALL ORGANS, TISSUES AND EYES
ORGANS
TISSUES
HEART
INTESTINES
EYES/CORNEAS
VEINS
LUNGS
SMALL BOWEL
HEART VALVES
FASCIA
LIVER (AND ASSOCIATED VESSELS)
BONE
SKIN
KIDNEYS (AND ASSOCIATED VESSELS)
TENDONS
NERVES
PANCREAS/ISLET CELLS
LIGAMENTS
For The Following Purposes Authorized By Law:
ALL PURPOSES
TRANSPLANTATION
THERAPY
RESEARCH
EDUCATION
OPTION 3
Please take me out of the Ohio Donor Registry.
SIGNATURE OF DONOR REGISTRANT
DATE
X
BMV 3346 11/09

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