YALE UNIVERSITY SCHOOL OF MEDICINE
DONATIONS OF BODIES FOR MEDICAL STUDY
Please fill out this form, print it and mail it to us. You may also print it first
and fill it out by hand. Be sure to keep a copy for your records.
Pursuant to Section 19a-279 of the Connecticut General Statutes (see next page),
I, (___________________________________________________________),
Hereby give my body to be delivered after my death as provided in the aforementioned
law, to the Yale University School of Medicine to be used in the advancement of medical
education and research. If I should die and not be in accordance with the criteria set forth
by the medical school this gift shall be null and void.
___________________________________
Witness
_________________________________
Signature of Donor
___________________________________
Address of Donor
_________________________________
Birth date of Donor
_________________________________
Date Signed
Sign and return to:
Yale Medical School, Department of Surgery
Section of Anatomy and Human Development
300 Cedar Street, P.O. Box 208062, New Haven, CT 06520-8062