UMMC Anatomical Gift Program Authorization Form

I, the undersigned, being 18 years of age or older, wish to donate my entire body upon my death to the University of Mississippi Medical Center (UMMC) Anatomical Gift Program for anatomical study, research, and the advancement of medical science.

I fully understand that the UMMC Anatomical Gift Program may not be able to accept my body at the time of death , in which case my next-of-kin/agent will make other arrangements for final disposition at their expense or the expense of my estate. View Criteria for Non-acceptance

Contact Information
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Vital Statistics (information will be used to complete Death Certificate)
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Agent Information
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Disposition of Cremains
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Next-of-kin/Executor of estate
Medical History
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Additional Information
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Signature

By typing my name below, I am signing this application electronically and acknowledging that this electronic signature has the same legal force and effect as a manual signature.

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