The Lions Clubs of District 20-Y2

Serving New York State's Capital District and Eastern Leatherstocking Region

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Leave a Legacy of Sight

Have you ever thought about being an eye donor? Every year, thousands of people, from babies to senior adults, lose their eyesight. In many cases, it can be restored with a corneal transplant. When you pledge your eyes, you give someone the hope of being able to see.

With more than a 90% success rate, corneal transplants are the most successful form of transplant surgery. All eye tissue is used regardless of the age of the donor, either through surgery or research. There is no cost to the donor family for any of the services. To become an eye donor, just print out this form and keep it with you, or you can sign the back of your NY driver's license. If you have questions, please contact us at one of the numbers below the form.

Lions Eye Bank at Albany
Sight Society of Northeastern New York , Inc.

This is to certify that _____________________________ has donated his/her eyes at death to the Sight Society of Northeastern New York, to be used to help restore sight of an individual suffering from corneal blindness and/or for research seeking to prevent blindness and find cures for diseases of the eye.

Signature of the donor ____________________________________________

Date of Birth ___________________      Date signed ____________________

Signature of companion/witness ____________________________________

Telephone number __________________

Signature of second witness (pref. next of kin) ____________________________________

Telephone number __________________

This is a legal document under the Uniform Anatomical Gift Act or similar laws.

Lions Eye Bank at Albany
6 Executive Park Drive, Albany, NY 12203
Phone: (518) 489-7606; FAX: 518-489-7607