General Information About Donor:

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Birth Place:

If my body is accepted, the final disposal of my remains may be made by the said Department of Anatomy and Cell Biology as follows:

An organ or part from my body may be so useful for teaching purposes that it will be desirable to preserve it for study by future students. To prevent deterioration, the Department of Anatomy and Cell Biology may wish to preserved or "plastinate" a body part or organ(s) for long term use.

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General Information About Family:


Father's Place of Birth:


Mother's Place of Birth:

Executor Information

General Information About Next of Kin:

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