SUPPLEMENTARY INFORMATION ABOUT DONOR
Please include the following information with the donation form and return to the Yale Medical
School. This information is used to complete the death certificate.
Name: _____________________________________________________________________
Sex: _____________________
Address:
______________________________________________________________________________
_________________
Date of Birth: ____________________________Place of Birth:
_____________________________________________
SS# ____________________________ Occupation:
__________________________________________________________
(Prior to retirement)
Married: _______ Widowed: __________ Single: ________ Divorced: ______________
Veteran: ___________
Spouse: (If wife give maiden name):
________________________________________________________________
Father’s name:
______________________________________________________________________________
__________
Mother’s name:
______________________________________________________________________________
_________
Highest level of education:
__________________________________________________________________________
Permission for Final Disposition
__________________, I give permission for Yale to dispose of my remains
by cremation and burial of remains in a plot owned by Yale at Evergreen
Cemetery, New Haven, CT
__________________, I request that my remains be cremated and returned
to
my next of kin, _______________________________
_____________________________________
____________________________________________
Donor Signature
Witness Signature
______________________________________
___________________________________________
Date
Date