- 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”.
(Legal name as reflected on the donor’s Social Security records. Include Jr., Sr., II, III, etc. if applicable)
PERSONAL INFORMATION OF DONOR
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: