GIFT OF HUMAN ANATOMY TO THE UNIVERSITY OF MICHIGAN

      Pursuant to the provisions of the Uniform Anatomical Gift Act, Article 10 of the Michigan Public Health Code, I hereby give my whole body, to be delivered after my death as provided in the aforementioned law, to the Anatomical Donations Program of the University of Michigan Medical School to be used in medical education and research. I also permit use of my medical information by the Anatomical Donations Program.

I have checked those statements below that apply to my intended donation.
  My body may be used in any manner that the University of Michigan Medical School deems necessary.
  Part or all of my body may be permanently preserved for teaching purposes.
  I am registered with an organ/tissue donation agency (see Organ Donation).
Has a relative donated to the Anatomical Donations Program before?     Yes     No       Name of Relative: _____________________________

Send one signed and witnessed copy of this form to: Anatomical Donations Program, The University of Michigan Medical School, 3767 Medical Sciences Building II, Ann Arbor, MI 48109-0608. Keep a copy of this form for your records.

_______________________________________________
Print Donor Name

_______________________________________________
Donor Signature

_______________________________________________
Print Donor Address

_______________________________________________

_______________________________________________

____________________________(_____)____________
Donor Date of Birth                   Donor Telephone Number
_______________________________________________
WITNESSES (2 required):

_______________________________________________


_______________________________________________
Date Signed