Donation

Phone Number

First Name

Last Name

Have you ever been diagnosed with any of the following:

Hepatitis B

Yes

Hepatitis C

Yes

Creutzfeldt-Jacob

Yes

Tuberculosis

Yes

Have you been incarcerated in a State or Federal Prison?

Yes

Do you have a history of intravenous Drug Use?

Yes

IMPORTANT NOTICE:

Make sure that all information disclosed in this form are accurate and matches legal records. Any inaccuracies such as misspelled or unreadable words can invalidate the death certificate DonorCure will release.
Please write legibly in CAPITAL letters.
For questions with no determinable answer, please write “UNKNOWN”.

Donor's last name

Donor's first name

Maiden or Prior Name (if applicable)

(Legal name as reflected on the donor’s Social Security records. Include Jr., Sr., II, III, etc. if applicable)

PERSONAL INFORMATION OF DONOR

Donor's Date of Birth (mm/dd/yyyy) format

Place of Birth

Gender

Never Married

Married

Widowed

Divorced

Spouse with maiden name

Social Security No.

I prefer to provide it over the phone

Highest Education Level

Profession or Occupation

Industry

Caucasian

African American

Asian

Native American or Alaskan Native

Native Hawaiian

Other Native Pacific Islander

Of Hispanic Origin:

Yes

US Military Service:

Yes

Branch

Discharge Date (mm/dd/yyyy) format

Street Address

City

County

State

Zip Code

How long has the deceased been living in this address?

Permanent Residence:

Same as current residence

Street Address

City

County

PARENTAL INFORMATION

Father’s Name

Birthplace

Mother’s Name

Birthplace

Mother’s Maiden Name

IMPORTANT NOTICE:

I certify that the information provided above are true and correct to the best of my knowledge. DonorCure, its employees, and affiliates are hereby released from any claims and liabilities arising from erroneous representation of any information in this form. In witness whereof, I hereby affix my signature:

Print Name

Date Signed (mm/dd/yyyy) format

Address

City

State

Zip Code

This form must be completed by the donor, health agent or legal next of kin. Incomplete or inaccurate forms will be returned for corrections and can delay the donor approval process.

Donor's last name

Donor's first name

Donor's Date of Birth (mm/dd/yyyy) format

(Legal name as reflected on the donor’s Social Security records. Include Jr., Sr., II, III, etc. if applicable)

currently receiving hospice care

has a life expectancy of six months or less

self	health agent	spouse	adult child
parent	sibling	next degree kindred	estate representative

I understand that

this whole body donation gift is motivated exclusively by altruistic intentions without financial compensation or valuable consideration made to me or any family member.
an autopsy will NOT be performed to determine the cause or contributing factors that led to the death of the donor.
no guarantee has been given that this donation will benefit a specific use, research, or educational study. This donation may benefit multiple educational, scientific, organ procurement and medical research organizations, for profit or nonprofit, domestic or international, and the education or research institution may perform final specimen disposition.
determination of acceptance of donation will be made at the time of passing. DONORCURE reserves the right, at their sole discretion, to decline acceptance of the donation and related charges if it appears unsafe or unsuitable for the purposes consented to herein.
upon acceptance of donation, DONORCURE will be responsible for any costs related to the donation including transportation, cremation, obtaining a copy of the donor’s death certificate, and return of cremated remains to the family or a scattering of cremated remains at sea.
the donor’s body will be transported to a DONORCURE facility. All protected health information as defined by the Health Insurance Portability and Accountability Act (HIPAA) will remain confidential and be kept in a secure location.
an open casket viewing is not possible with whole body donation and no un-cremated remains will be returned. The cremated remains returned will not include body tissues, organs, or anatomical specimens procured for medical education or research purposes.
DONORCURE and all associated agents, including specimen end-users, shall not be liable from loss or damage, including incidental and consequential damage which results from the undersigned not having proper legal authority to consent
signing this document does NOT guarantee acceptance of donation
any material misrepresentation of body condition or medical history causing the donor to be unacceptable for donation may result in the donor family being responsible for expenses incurred by DonorCure, Inc.

I hereby authorize

the procurement of all necessary tissues, organs, and anatomical specimens, including whole body, for medical research and educational purposes and understand tissue/specimens may be used indefinitely into the future. I understand that the body may be subject to extensive preparation and/or long-term preservation, including but not limited to, removal of the head, arms, fingers, legs, toes, hands, feet, spine, organs, tissues, or fluids, both domestically and internationally.
for any and all medical information to be released to DONORCURE before or after death, including but not limited to, a complete medical history and blood samples. Blood testing may occur which can include, but is not limited to, HIV, hepatitis B and hepatitis C. Positive blood test results for HIV will be communicated to the Health Department. A positive result for HIV, hepatitis B or hepatitis C will also be communicated to the next of kin.

I further authorize this whole body donation for additional education and research uses, such as weapons testing and personal protective gear (for example military); search, rescue, and recovery operations; forensic pathology and crime scene investigation; educational display; plastination (permanent plastic fixation of body tissues); or automobile safety research. In some cases such research or education may involve destruction of the body or parts of the body.

Yes

Please Send Death Certificate to (name)

Phone Number

Relationship to donor

Address

City

State

I hereby confirm that I understand and consent to all the above-listed disclosures as indicated by my signature below:

Print Name

Date Signed (mm/dd/yyyy) format

Address

City

State

This form must be completed by the donor, health agent or legal next of kin. Incomplete or inaccurate forms will be returned for corrections and can delay the donor approval process.

Donor's last name

Donor's first name

Donor's Date of Birth (mm/dd/yyyy) format

Has a death occurred?

Donor's Date of Death (mm/dd/yyyy) format

(Legal name as reflected on the donor’s Social Security records. Include Jr., Sr., II, III, etc. if applicable)

This is to authorize DONORCURE and its affiliated crematory, hereinafter referred to as “crematory”, to cremate the body of the above-named donor subject to applicable regulations and the following disclosures:

I understand that

the crematory may place the body in a rigid enclosed container for sanitary purposes.
dental fillings, bridgework, gold inlays, prostheses, jewelries and other non-organic items shall be removed from the body and discarded
the cremation process normally involves pulverizing and grinding the cremated remains
the cremated remains that are returned to the family or scattered at sea may or may not represent all the tissue of the donor.
some parts of the cremated remains that are deemed irreclaimable during the cremation and containerization cannot be returned to the family
the cremated remains will be placed in a standard sized container; any excess shall be placed in a supplementary container and will be returned to the family together with the primary container.
this consent form does not constitute a contract of service with DonorCure and its affiliates but an expression of informed consent for the purpose herein stated
the cremation process shall be conducted in accordance with all applicable laws of this country and the state with which the cremation has taken place
the cremated remains shall be returned by way of express mail; otherwise it will be scattered at sea subject to DonorCure’s discretion and applicable internal policies.

I hereby authorize

I hereby agree that DonorCure along with its employees, contractors, agents, and affiliates (including but not limited to the crematory and beneficiary medical research facilities) is released from all liabilities, claims, and damages arising from the reliance or performance of the conditions and disclosures stated herein.

Does the donor have a pacemaker?

Yes

Has the donor received any intravenous or surgically implanted radiation treatments?

Yes

Does the donor have any dental implants or prostheses?

Yes

DISPOSITION OF CREMATED REMAINS

(Please choose only one option)

Please return cremated remains to the address below:

Street Address

City

State

Zip Code

Phone Number

Please dispose of the remains at sea

Notify me

Don’t notify me

Upon my oath and under penalty of perjury, I hereby certify to the best of my knowledge all information presented herein is correct and that no other person is previously authorized to give permission for the cremation and disposition of the donor’s remains. To verify my consent and understanding to the terms and conditions herein stipulated, I hereby affix my signature.

self	health agent	spouse	adult child
parent	sibling	next degree kindred	estate representative

Date Signed (mm/dd/yyyy) format

Address

City

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Register As A Donor

REGISTER DATA

VITAL INFORMATION FORM

IMPORTANT NOTICE:

PERSONAL INFORMATION OF DONOR

RESIDENCE

PARENTAL INFORMATION

IMPORTANT NOTICE:

AUTHORIZATION OF BODY GIFT

I understand that

I hereby authorize

CREMATION AUTHORIZATION

I understand that

I hereby authorize

DISPOSITION OF CREMATED REMAINS