Anatomical Gift Donation Form

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Being of sound mind and legal age, it is my desire to bequeath my remains, if acceptable at the time of my death, to ETSU Quillen College of Medicine for the advancement of medical education If this donor form or a copy thereof is found on my person or among my effects at the time of my death, I authorize and request any person attending or present at such time to notify ETSU Quillen College of Medicine for transport of my unembalmed body to the College of Medicine. No autopsy should be performed. I direct my next-of-kin, executor or agency entitled to my body after death to cooperate with ETSU Quillen College of Medicine to carry out my wishes in this donation as indicated on this form. Please fill out the Anatomical Gift Donation Form and we will contact you within 2 business days.

Return to Quillen College of Medicine, Department of Medical Education, PO Box 70582, Johnson City, TN 37614-1708

Donor's Information:

First Name:

Middle Name:

Last Name:

Email:

Phone Number:

Emergency Name:

Emergency Contact Number:

Donor's Address:

Street:

City:

State:

Zip:

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