Willed Body Program Release Of Liability printable pdf download

Willed Body Program Release Of Liability

THE UNIVERSITY OF TEXAS

OUTHWESTERN

EDICAL

ENTER

W I L L E D B O D Y P R O G R A M

5323 HARRY HINES BLVD. DALLAS, TEXAS 75235-9143 / (214) 648-2221 FAX (214) 648-4506

Willed Body Program Release of Liability

I, ___________________, next of kin of _____________________

(Name of next of kin)

(Name of deceased)

Authorize the Willed Body Program staff to perform the removal of the

brain on the deceased for research purposes. This removal may also

include the removal of the spinal cord, if indicated by the department

requesting the removal.

I authorize the Willed Body Program staff to transport the remains of

my deceased to their facility, if needed, to perform this removal.

___________________________ _ _________________

Next of kin (please print)

Date and time signed

___________________________________________

Signature of next of kin

___________________________________________

_____________________________

Signature of witness

Date and time signed

Read Important Instructions

WilledBody.doc

Willed Body Program Release Of Liability