AN EQUAL OPPORTUNITY INSTITUTION
ANATOMICAL BOARD OF THE
STATE OF FLORIDA
University of Florida
College of Medicine
Health Science Center
PO Box 100235
Gainesville, FL 32610-0235
Telephone: 352-392-3588
1-800-628-2594
Miami Office:
University of Miami
Miller School of Medicine
Office of Medical Education
P.O. Box 016960 (R-160)
Miami, FL 33101-6960
Telephone: 305-243-6691
Orlando Office:
University of Central Florida
College of Medicine
Health Sciences Campus
at Lake Nona
6850 Lake Nona Blvd.
Orlando, FL 32827-7408
Telephone: 407-266-1142
DEDICATION FORM
I, , the undersigned, desire that my body, at the
time of death, be given to the Anatomical Board of the State of Florida for use in
education and research. It is understood that the Anatomical Board of the State of Florida
can accept my body only if I become deceased within the geographical limits of the State
of Florida or if agencies or individuals other than the Anatomical Board assume
responsibility for returning my body to the State of Florida.
It is also understood that this is a legal document in that it is a statement of my wish
and intention to dedicate my body for medical use, as provided in Chapter 406.50 through
406.61 and Chapter 765.510 through 765.514, Florida Statutes. In order that this wish be
promptly and effectively carried out after my death, I accept responsibility for obtaining the
consent of all my relatives or close friends likely to have any concern about the final
disposition of my body. After completion of use by the University or other educational
institution and unless otherwise specified below, the remains will be cremated and distributed
pursuant to donor’s instructions for disposition. At times, the body may possess certain
unique structures, either anatomical or pathological, that would greatly benefit anatomical
education and medical research and may not be recovered for cremation.
Date of Birth: _ _ - _ _ - _ _ _ _ ______________________________
Signature
Driver License #: _ _ _ _ - _ _ _ - _ _ - _ _ _ _______________________________
Address
Social Security #: XXX – XX – _ _ _ _ ________________________________
City State Zip Code
Signed in the presence of these witnesses on this day of 20 .
Witness: Witness:
________________________________ ________________________________
Signature Signature
________________________________ ________________________________
Address Address
________________________________ ________________________________
City State Zip Code City State Zip Code
