Body Bequeathal Sign Up Form - College of Medicine

General Information About Donor:

* required fields

Title:

* Legal Last Name:

* Legal First Name:

Preferred First Name:

Maiden Name:

* Marital Status:

Spouse Name:

* Birth Date (mm/dd/yyyy):

* Sex:

* Address:

* City:

* Province:

* Postal Code:

* Home Phone Number:

Cell Phone Number:

Other Phone Number:

Email Address:

* Health Card Number:

Occupation held during majority of life:

Birth Place:

* City:

* Province:

* Country:

* Family Physician Name:

* Family Physician Full Address:

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:

It be cremated and the cremated remains returned to the person designated below

It be cremated and the cremated remains interred in Woodlawn Cemetery, Saskatoon, Saskatchewan

It be cremated and other arrangements be made by and at the expense of my estate

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.

Please check if you agree with the following:

Part or all of my body may be permanently preserved for teaching purposes at the College of Medicine, University of Saskatchewan, as determined by the Department of Anatomy and Cell Biology.

General Information About Family:

Father

* Surname:

* Given Names:

Father's Place of Birth:

* City:

* Country:

Mother

* Maiden Name:

* Given Names:

Mother's Place of Birth:

* City:

* Country:

Executor Information

Check if none

Executor's Name:

Contact Number:

Email Address:

Address:

City:

Province:

Postal Code:

General Information About Next of Kin:

Title:

* Family Name:

* Given Names:

Email Address:

* Relationship to Donor:

* Address:

* City:

* Province:

* Postal Code:

* Home Phone Number:

Cell Phone Number:

Other Phone Number:

Please do not click Submit more than once!