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University of Florida |
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I,
___________________________________________, the undersigned, desire that my
body, at the time of death, be given to the Anatomical Board of the State of
Florida for use in medical research and education. It is understood that the
Anatomical Board of the State of Florida can accept my body only if I become
deceased within the geographical limits of the State of Florida or if
agencies or individuals other than the Anatomical Board assume responsibility
for returning my body to the State of Florida. It
is also understood that this is a legal document in that it is a statement of
my wish and intention to dedicate my body for medical use, as provided in
Chapter 406 and Chapter 765 Part IV, Florida Statutes. In order that this wish be
promptly and effectively carried out after my death, I accept responsibility
for obtaining the consent of all my relatives or close friends likely to have
any concern about the final disposition of my body. It
is possible that an individual's body may be utilized for research or medical
education outside of the State of Florida. Kindly strike out the appropriate
word/words in the statement below to indicate approval or disapproval of such
use. Also place your initials at the end of the statement. I
(do) (do not) object to the utilization of my body for medical research and
education in an approved institution outside the State of Florida.
______________ (Initial) Signed
in the presence of these witnesses of this ________ day of
_____________________________ 20 ________. |
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Date
of Birth: ______-_____-______ Driver
License #:_____-______-____-___________ Social
Security #:_____-______-_____________
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Please print TWO copies of this form. Return one completed form with original signatures to the Anatomical Board and retain the second for your records. |
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