Fillable Donor Application UCSF Willed Body Program (University of California, San Francisco)

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Donor Application UCSF Willed Body Program (University of California, San Francisco)

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1
Donor’s Name: __________________________________
General Instructions 2
Vital Statistics 3
Worksheet for Education and Race/Ethnicity 4
Donation Agreement 5-14
Privacy Act Notification 15
UCSF Willed Body Program
School of Medicine, AC-14
UCSF Box 0902
San Francisco, CA 94143
415-476-1981
415-502-1460 fax
willedbodyprogram.ucsf.edu
Donor Application
2
UCSF Willed Body Program
School of Medicine, AC-14
UCSF Box 0902
San Francisco, CA 94143
415-476-1981
415-502-1460 fax
willedbodyprogram.ucsf.edu
Thank you for your interest in the UC San Francisco Willed Body Program. Enclosed you will find our
donor registration application. Upon completion of this application, please mail it to the address above.
You should expect confirmation of your registration within three weeks of mailing your application to us.
All donor registration forms must be completed and signed where indicated. The UC Donation Agreement
will require a signature witnessed by two people or a Notary Public. Mail the completed forms, which
include the entire donor application, to the UCSF Willed Body Program in the envelope provided or to
the address noted above. Once the forms have been reviewed and accepted by the Program, an
acknowledgement will be sent to you along with a donor identification card.
Please feel welcome to call the program at 415-476-1828 for questions or assistance in completing the
forms. All information provided will remain confidential to the extent allowed by law.
Vital Statistics Sheet
The information provided is of great value to teaching and research and is also required to complete
certain government forms. The information will also be used for completion and processing the death
certificate with the State of California, Office of Vital Records. All boxes must be completed to the best of
your ability. If you do not have the information for an item, write “unknown” or “none” in that space. Do
not leave any blank boxes. Please PRINT all information and double check for spelling errors.
Worksheet for Education and Race/Ethnicity
This form is a guide when completing certain items found on the Vital Statistics form.
Donation Agreement
Please sign this form in front of two witnesses or a Notary Public (if you are signing the donation agreement
for yourself). If the donation is made by the authorized agent under a valid durable power of attorney
for healthcare or directive that expressly authorizes the agent to make an anatomical gift of all or part of
the principal’s body, a complete legible copy of the durable power of attorney for health care or directive
must accompany this form.
3
Vital Statistics
Donor name______________________________________________________________ Male ________ Female __________
First Middle Last
Aka_____________________________________ Phone (_______)____________________________
Usual Address __________________________________________________________________________________________
Street City State/Zip Code
County of Residence_________________________________ No. Of years in this county ____________________________
Race/Ethnicity___________________________ Spanish/Hispanic: Yes_______No________Specify ____________________
Please complete the attached education and race identity worksheet
Date of birth_________________ State of birth__________________________ or Foreign country ______________________
Full name of father _____________________________________________ Birthplace of father _________________________
First Middle Last
Full maiden name of mother _______________________________________ Birthplace of mother _____________________
First Middle Last
Social Security #____________-___________-_____________ US Armed Forces: Yes_______ No_______ Unknown _____
Marital status: Never married Married Widowed Divorced Reg. Domestic partner
Name of surviving spouse (if wife, enter maiden name) _________________________________________________________
First Middle Last
If you are now retired, please give employment information on your occupation before retirement:
Usual occupation ___________________________________________________ years in occupation ___________________
Kind of industry or business _______________________________________________________________________________
Education (highest level/degree completed- see worksheet) ____________________________________________________
Name of physician_________________________________________________ Phone no. _____________________________
Height___________________Weight__________________ Present state of health ___________________________________
Surgical history: knee, hip, shoulder, spine or other joint? ______________________________________________________
Hysterectomy or Prostatectomy? ___________________________________________________________________________
Disease history or treatment: Hepatitis A, B or C, HIV/AIDS, Tuberculosis, others (MRSA, Creutzfeldt-Jakob)?
________________________________________________________________________________________________________
Additional health information including illnesses, operations, accidents: ___________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
How did you hear of the program: Friend Program Website Facebook/Instagram/Youtube Newspaper
UC Publication/Presentation Doctor’s office/Hospital Advanced Directive Other: ________________________
Last revision: 12.19.2018
4
State of California - Health and Human Services Agency Department of Health Services
Worksheet for Education and Race/Ethnicity (for Reference only)
Notice to Informants (aka responsible party/survivor): The information requested is essential for determining the health problems
of the population groups noted below and your cooperation is appreciated. Completion of this work sheet in conjunction with
the “Certificate of Death” is mandatory.
DECEDENT’S EDUCATION - Check
the box that best describes the highest
degree or level of school completed at
the time of death.
Enter appropriate information in box
No. 13.
0-11th grade.
Enter highest year
completed: ________
12th grade, but no diploma.
Enter 12
High school graduate or GED
completed. Enter either HS
GRADUATE or GED:
__________________
Some college credit, but no
degree. Enter SOME COLLEGE
Associate degree (e.g., AA,
AS). Enter ASSOCIATE
Bachelor’s degree (e.g., BA,
AB, BS). Enter BACHELOR’S
Masters degree (e.g., MA, MS,
MEng, ME d, MSW, MBA). Enter
MASTER’S
Doctorate (e.g., PhD, EdD) or
Professional degree (e.g., MD,
DDS, DVM, LLB, JD). Enter either
DOCTORATE or
PROFESSIONAL.
WAS DECEDENT
SPANISH/HISPANIC/LATINO?
If not Spanish/Hispanic/Latino,
check “NO” in box No. 14/15.
If Spanish/Hispanic/Latino, check
“YES” in box No. 14/15 and enter
specific origin.
No
Yes, Mexican, Mexican
American, or Chicano
Yes, Central American
Yes, South American
Yes, Cuban
Yes, Puerto Rican
Yes, other -
Spanish/Hispanic/Latino
Specify:
__________________________
WHAT WAS DECEDENT’S RACE OR
ETHNICITY? (Check one or more races
to indicate what the decedent considered
himself or herself to be)
Enter text for up to 3 races in box
No. 16.
White
Black, African American, or Negro
American Indian or Alaska Native
(North, South, and Central American
Indian) Specify Tribe(s)
___________________
Native Hawaiian
Guamanian
Samoan
Other Pacific Islander
Specify:
________________________
Asian Indian
Cambodian
Chinese
Filipino
Hmong
Japanese
Korean
Laotian
Vietnamese
Other Asian
Specify:
________________________
Other
Specify:
________________________
Race Abbreviations:
American Indian = AMER IND
Cambodian = CAMBODIA
Guamanian = GUAMIAN
Asian Indian = SIA IND
Vietnamese = VIETNAM
Pacific Islander = PACIF IS
5
UNIVERSITY OF CALIFORNIA DONATION AGREEMENT
1. INFORMATION ON THE UC ANATOMICAL DONATION PROGRAM
The UC Anatomical Donation Program (also known as the donated body, body donation, willed body
or anatomical materials program, but referred to as “Program” in this document) accepts donations of
human bodies for use by various institutions and individuals for education and research purposes. The
Program’s goals are:
1. Assisting the education of current and future physicians, other healthcare practitioners, anatomists,
forensic scientists and mortuary technicians.
2. Contributing to scientific research that will assist in development of procedures and/or products
with the intent of improving the human condition in biomedical and scientific contexts.
Based on the Program’s current and future policies and procedures, the Program will exclusively determine
the manner in which a donated body and any data, including images, derived from the donation will be
utilized. The Program may support others in the development of commercialized products in a limited
manner; for example, with the use of non-identifying images in text books or other instances where the
primary benefit of the use is for education and research. Section 3 of this donation agreement provides
additional information about the use of bodies donated to UC.
When this agreement has been completed and the Program has confirmed registration, the donor will be
provided with a Donor Card that contains the necessary information to contact the Program at the time
of death.
Donations will remain confidential. Once a donor’s remains have been accepted into the Program,
acknowledgement will be sent only to the person, or persons, designated by a donor in this application.
“Donor” as used in this agreement means the individual whose body or part is the subject of the
anatomical gift.
Due to the nature and variability of uses for scientific research and education, cremated remains or any
by-products of the cremation process WILL NOT be returned. By signing this agreement, you, as a
donor or a donor’s legal representative, acknowledge that remains will not be returned and specifically
waive the provisions of California Health & Safety Code Section 7151.40(b) that provides for the return of
cremated remains to certain individuals. The Program will not offer exceptions to this policy and encourages
potential donors to consider the impact of this policy on their families or communities.
Initials___________________
Last revision: 12.19.2018
6
2. INSTRUCTIONS FOR SURVIVORS (RESPONSIBLE PARTY)
1. Upon the death of a donor, please notify the Program of the death immediately, as a delay can
result in rendering the remains unusable to the Program. Please ensure that body is not embalmed
and is otherwise unprepared.
2. Although every effort will be made to accept a donor’s body, the Program may decline a donation
at the time of death at its sole discretion. While this situation is unusual, please consider alternative
arrangements for the disposition of the body should the body be deemed unsuitable for donation.
3. The University of California accepts donations throughout the State of California and, in special
circumstances, from neighboring states. Upon notification of a donor’s death, donors are typically
received by the campus program location that is geographically closest. However, the university
shall have the option of:
a. arranging for the body to be accepted by any University of California Anatomical Donation
Program location.
b. declining to accept the donation of the body.
4. The Program will have an original certificate of death filed with the county where death occurs, in
compliance with the Registrar of Births and Deaths. The donor’s responsible party must obtain
necessary copies of the certificate of death. The Program will provide the contact information for
the local Registrar.
5. Third-party donations (for example, donations made by an Agent named on a Durable Power of
Attorney for Health Care or the person who has control over the disposition of the decedent’s body)
may also be accepted. Individuals making third-party donations must sign the required documentation
found in this agreement specifying that they are compliant with the stated criteria.
6. Upon a donor’s death, the Program will send an acknowledgement letter to a family member or
friend (the person or persons you have designated in the fields below) or may contact that person
to verify information for the certificate of death or for other reasons. You may decline to designate a
recipient or you may designate more than one person. If you are signing on behalf of the donor, you
may designate yourself.
Name(s)______________________________________ Relationship(s)_______________
Address__________________________________________________________________
City/State/Zipcode_________________________________________________________
Phone number/Email_______________________________________________________
OR
I elect not to name a recipient: _________
Initials___________________
Last revision: 12.19.2018
7
3. USE OF DONATED BODIES
Whole body donors may be used in the following manner:
1. The program will determine medical suitability of a donated body through a process that may
include review of medical records, a medical or social history questionnaire and/or serology testing.
Testing may include obtaining a blood sample to screen for Hepatitis B, Hepatitis C, HIV, or other
communicable diseases that may render the body as medically unsuitable for donation. Results of
tests will not be disclosed to the donor’s designated survivor/responsible party but will be reported
to the California Department of Health Services if mandated by law.
2. A donated body may be chemically preserved by the Program or used in a non-embalmed state
as anatomical material.
3. A donated body may be dissected, examined, studied, and preserved for a substantial period of
time, including the possibility of permanent retention, and may be used for more than one purpose.
Parts of the body such as limbs or organs may be removed and separated from the whole. Bodily
fluids and tissues may be analyzed and destroyed.
4. A donated body and/or part of the body may be provided to educators, students, researchers or
others at University of California campuses, as well as to other educational institutions, researchers,
non-profit entities and entrepreneurial entities, such as those who develop surgical instruments or
healthcare products. When a donation is made, donors, survivors and/or responsible parties cannot
designate the uses to which the body will be put nor the persons or entities that will use the body.
The University of California reviews requests for uses and approves them on a case by case basis
according to their scientific and educational merit.
5. The Program may support the development of commercialized products in a limited manner when
the primary benefit of the use is for education and research (for example, in textbooks, or educational
software).
6. Donor data, including health data and images, derived during the registration, donation or use may
be used for education and research purposes. Data will be de-identified and stored or shared securely.
7. The Program shall be entitled to recover all of its acquisition, preservation, storage, transportation,
disposition and related costs (both fixed and non-fixed) from the approved researcher or educator
(end-user).
8. If it is determined that, for any reason, a body cannot be used by the Program, or by any educator
or researcher approved for use of anatomic material donated to the Program, it will be cremated or
undergo a final disposition in a manner consistent with the existing California law. Personal belongings
received with a body including eyeglasses, dentures or pacemakers may be donated, refurbished
or recycled. Other items such as clothing or bedding will be discarded.
Initials___________________
Last revision: 12.19.2018
8
4. DISPOSITION OF DONATED BODIES
The following applies to the ultimate disposition of donor bodies by the Program. By signing this Agreement,
a donor or his/her responsible party authorizes the Program and its agents to dispose of the donor by
cremation or by another legal manner that may be approved at the time of death.
1. Because parts of the body may be removed during its use, these parts may be disposed of at
different times and at different locations. Upon completion of the use of the body or any part of the
body, the material may be cremated or otherwise disposed of by any means permitted under state
law in effect at the time of disposition.
2. Under certain circumstances, body parts, tissue and fluids may undergo disposition with material
from other donors, in accordance with California law.
3. Survivors/responsible parties will not be notified of the time, place or manner of the disposition of a
body or any part of a body, or of the final disposition of the remains. The cremation of some parts
of the body may not result in the creation of any remains for disposition due to the composition of
those body parts.
4. The donor or legally responsible person signing on behalf of the donor expressly waives the provisions
of California Health & Safety Code Section 7151.40(b) that provides for the return of cremated
remains. Due to the nature and variability of uses for scientific research and education, cremated
remains or any by-products of the cremation process WILL NOT be returned.
Initials___________________
5. INFORMATION ON HOW TO REVOKE A DONATION
Donations may be revoked in accordance with the California Health and Safety Code. The process to
revoke a donation is different for a person donating his/her own body (self-donation) and for a donation
made by another (authorized person). Please read and acknowledge your understanding of how to
revoke a donation by affixing your initials.
1. Self-Donation
A donor may revoke an anatomical donation at any time prior to death. After death, this donation
cannot be revoked by survivors/responsible parties and survivors/responsible parties cannot change
any term or condition of the gift. By signing this agreement, a donor intends for the University of
California to have the exclusive right to control the use and disposition of their body upon death.
2. Donation made by another authorized person
An authorized person, other than the decedent, who has the legal right to make a donation according
to California Health and Safety Code 7150.40, may revoke an anatomical donation only if, before
an incision is made or an invasive procedure has begun to prepare the donor, the Program is made
aware of the revocation.
Initials___________________
Last revision: 12.19.2018
9
Please complete section 6 if you are signing for yourself. If you are signing on behalf of the donor, proceed
to section 7. Please note that only the donor or agent with durable power of attorney for healthcare may
sign prior to the death of a donor.
6. PLEASE COMPLETE THIS SECTION WHEN SIGNING FOR YOURSELF.
I, ___________________, hereby donate my body upon my death to the University of California pursuant to the
terms and conditions set forth herein. I am at least 18 years of age. I adopt these descriptive and declarative terms
and conditions as my own and make them my instructions for the disposition of my body upon my death. I have
read and considered all of the information contained in this Donation Agreement. I have initialed each section of
the Agreement indicating my understanding of the information and my desire to donate my body pursuant to this
Agreement.
__________________________________________________________________________________________________
Signature Date
__________________________________________________________________________________________________
Print Name
__________________________________________________________________________________________________
Address City/State/Zip
__________________________________________________________________________________________________
Phone/E-mail
Two Witnesses OR Notarization Required
This agreement must be either signed by two witnesses, with at least one as a “disinterested witness”, OR
may be notarized by a notary public in lieu of witnesses if you are signing this donation agreement for yourself.
1. WITNESSES
“Disinterested witness” means a witness other than the spouse, child, parent, sibling, grandchild, grandparent,
or guardian of donor, or another adult who exhibited special care and concern for the individual.
We, the undersigned, have witnessed the signing of this document by the donor.
______________________________ _____________________________
Signature of Witness Signature of Disinterested Witness
______________________________ _____________________________
Print Name Print Name
______________________________ _____________________________
Address Address
______________________________ _____________________________
City/State/Zip City/State/Zip
Last revision: 12.19.2018
10
2. NOTARIZATION
CERTIFICATE OF ACKNOWLEDGEMENT OF NOTARY PUBLIC
State of California
County of ____________________________
On ______________________ before me, ________________________________________________
(insert name and title of the officer)
personally appeared ________________________________________________________________,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same
in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under penalty of perjury under the laws of the State of California that the foregoing paragraph
is true and correct.
WITNESS my hand and official seal.
Signature __________________________________ (Seal)
(Signature of Notary Officer)
Last revision: 12.19.2018
11
7. Please complete this section if you are the spouse, registered domestic partner, or agent named in the durable
power of attorney for healthcare or the person who has control of the disposition of the decedent’s body.
I have read and fully understood the policies set forth in this document. As the legally responsible party under this section for
_________________________________________ (name of deceased) I wish to donate his/her remains to the University of
California. I accept all terms and conditions set forth in this document and I know of no express, contrary information indicating
that the decedent would not want to donate his/her body.
____ I am the spouse of the deceased donor.
____ I am the registered domestic partner of the deceased donor.
____ I am the agent for the donor with power of attorney for health care and I have the right and duty of disposition under
Division 4.7 (commencing with Section 4600) of the Probate Code or, I have been designated to control the donor’s
disposition in an Advance Health Care Directive. A copy of the Durable Power of Attorney for Healthcare or Directive
must be attached.
____ I am the declared claimant of the deceased donor and have completed the attached affidavit in support of this claim.
__________________________________________________________________________________________________________
Signature Relationship to Decedent Date
__________________________________________________________________________________________________________
Print Name
__________________________________________________________________________________________________________
Address City/State/Zip
__________________________________________________________________________________________________________
Phone/E-mail
TWO WITNESSES REQUIRED
This agreement must be signed by two witnesses, with at least one as a “disinterested witness”.
1. WITNESSES
“Disinterested witness” means a witness other than the spouse, child, parent, sibling, grandchild, grandparent, or
guardian of donor, or another adult who exhibited special care and concern for the individual.
We, the undersigned, have witnessed the signing of this document by the donor.
______________________________________ ______________________________________
Signature of Witness Signature of Disinterested Witness
______________________________________ ______________________________________
Print Name Print Name
______________________________________ ______________________________________
Address Address
______________________________________ ______________________________________
City/State/Zip City/State/Zip
Last revision: 12.19.2018
12
Last revision: 12.19.2018
8. AFFIDAVIT IN SUPPORT OF CLAIM TO CONTROL DISPOSITION OF BODILY REMAINS (Pursuant to Health and
Safety Code Section 7100). PLEASE COMPLETE THIS SECTION IF YOU ARE THE PERSON WHO HAS CONTROL
OVER THE DISPOSITION OF THE DECEDENT’S BODY.
Name of Decedent _______________________________________________________________________________________
Name of Claimant ________________________________________________________________________________________
Address of Claimant ______________________________________________________________________________________
______________________________________________________________________________________
Phone Number __________________________________________________________________________________________
Relationship to Decedent _________________________________________________________________________________
I claim the right to control the disposition of the Decedent’s bodily remains because: (check all that apply)
The Decedent named me to control the disposition of his or her body in a will or other document (attach a copy of the
document).
I am the Decedent’s (circle one) child, parent, grandparent or nearest other relative. (If you are the Decedent’s child,
you must have the approval of the majority of the Decedent’s children to arrange the disposition of the body. By signing
below, you represent that you have the approval of the majority of the Decedent’s children, or that you have made
reasonable efforts to notify all of the Decedent’s other children of your arranging the disposition of the Decedent’s body).
I am not aware of any person who objects to my arranging the disposition of the body of the Decedent.
I am not aware of any written or oral instruction by the Decedent, or any contract for funeral services by the decedent, that
give control of the disposition of the Decedent’s remains to any other person.
I am aware of and have received a copy of Health and Safety Code Section 7100 and agree to comply with the provisions
therein.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Signature __________________________________________________________ Date _________________________
13
Last revision: 12.19.2018
HEALTH AND SAFETY CODE
SECTION 7100
7100. (a) The right to control the disposition of the remains of a deceased person, the location and
conditions of interment, and arrangements for funeral goods and services to be provided, unless other
directions have been given by the decedent pursuant to Section 7100.1, vests in, and the duty of
disposition and the liability for the reasonable cost of disposition of the remains devolves upon, the
following in the order named:
(1) An agent under a power of attorney for health care who has the right and duty of disposition under
Division 4.7 (commencing with Section 4600) of the Probate Code, except that the agent is liable for the
costs of disposition only in either of the following cases:
(A) Where the agent makes a specific agreement to pay the costs of disposition.
(B) Where, in the absence of a specific agreement, the agent makes decisions concerning disposition
that incur costs, in which case the agent is liable only for the reasonable costs incurred as a result of the
agent’s decisions, to the extent that the decedent’s estate or other appropriate fund is insufficient.
(2) The competent surviving spouse.
(3) The sole surviving competent adult child of the decedent, or if there is more than one competent
adult child of the decedent, the majority of the surviving competent adult children. However, less than
the majority of the surviving competent adult children shall be vested with the rights and duties of this
section if they have used reasonable efforts to notify all other surviving competent adult children of their
instructions and are not aware of any opposition to those instructions by the majority of all surviving
competent adult children.
(4) The surviving competent parent or parents of the decedent. If one of the surviving competent
parents is absent, the remaining competent parent shall be vested with the rights and duties of this section
after reasonable efforts have been unsuccessful in locating the absent surviving competent parent.
(5) The sole surviving competent adult sibling of the decedent, or if there is more than one surviving
competent adult sibling of the decedent, the majority of the surviving competent adult siblings. However,
less than the majority of the surviving competent adult siblings shall be vested with the rights and duties
of this section if they have used reasonable efforts to notify all other surviving competent adult siblings of
their instructions and are not aware of any opposition to those instructions by the majority of all surviving
competent adult siblings.
(6) The surviving competent adult person or persons respectively in the next degrees of kinship, or if
there is more than one surviving competent adult person of the same degree of kinship, the majority of
those persons. Less than the majority of surviving competent adult persons of the same degree of kinship
shall be vested with the rights and duties of this section if those persons have used reasonable efforts
to notify all other surviving competent adult persons of the same degree of kinship of their instructions
and are not aware of any opposition to those instructions by the majority of all surviving competent adult
persons of the same degree of kinship.
(7) The public administrator when the deceased has sufficient assets.
(b) (1) If any person to whom the right of control has vested pursuant to subdivision (a) has been
charged with first or second degree murder or voluntary manslaughter in connection with the decedent’s
death and those charges are known to the funeral director or cemetery authority, the right of control is
relinquished and passed on to the next of kin in accordance with subdivision (a).
(2) If the charges against the person are dropped, or if the person is acquitted of the charges, the
right of control is returned to the person.
14
(3) Notwithstanding this subdivision, no person who has been charged with first or second degree
murder or voluntary manslaughter in connection with the decedent’s death to whom the right of control
has not been returned pursuant to paragraph (2) shall have any right to control disposition pursuant to
subdivision (a) which shall be applied, to the extent the funeral director or cemetery authority know about
the charges, as if that person did not exist.
(c) A funeral director or cemetery authority shall have complete authority to control the disposition of the
remains, and to proceed under this chapter to recover usual and customary charges for the disposition,
when both of the following apply:
(1) Either of the following applies:
(A) The funeral director or cemetery authority has knowledge that none of the persons described in
paragraphs (1) to (6), inclusive, of subdivision (a) exists.
(B) None of the persons described in paragraphs (1) to (6), inclusive, of subdivision (a) can be found
after reasonable inquiry, or contacted by reasonable means.
(2) The public administrator fails to assume responsibility for disposition of the remains within seven
days after having been given written notice of the facts. Written notice may be delivered by hand, U.S.
mail, facsimile transmission, or telegraph.
(d) The liability for the reasonable cost of final disposition devolves jointly and severally upon all kin of
the decedent in the same degree of kinship and upon the estate of the decedent. However, if a person
accepts the gift of an entire body under subdivision (a) of Section 7155.5, that person, subject to the
terms of the gift, shall be liable for the reasonable cost of final disposition of the decedent.
(e) This section shall be administered and construed to the end that the expressed instructions of the
decedent or the person entitled to control the disposition shall be faithfully and promptly performed.
(f) A funeral director or cemetery authority shall not be liable to any person or persons for carrying out
the instructions of the decedent or the person entitled to control the disposition.
(g) For purposes of this section, “adult” means an individual who has attained 18 years of age, “child”
means a natural or adopted child of the decedent, and “competent” means an individual who has not
been declared incompetent by a court of law or who has been declared competent by a court of law
following a declaration of incompetence.
Last revision: 12.19.2018
15
Privacy Act Notification
STATE
The California Information Practices Act of 1977 requires the University to provide information to the individual to whom the
information pertains.
Furnishing information requested in the Vital Statistic sheet is mandatory. Failure to provide such information will delay or may
even prevent completion of the action for which the form is being filled out. Information furnished on this form will be transmitted
to the state and federal governments if required by law.
Civil Code Section 1798.9 et seq. requires each state agency to provide notice to individuals completing this form (VS-11
Certificate of Death and VS 9 Application and Permit for Disposition of Human Remains). The information is being requested
by: Department of Health Services, Office of Vital Records, 304 S Street, P.O. Box 730241, Sacramento, CA 94244-0241.
The information requested on this certificate is authorized as required by Divisions 7 and 102 of the Health and Safety Code,
and related provisions with the Civil Code, Code of Civil Procedure, and Government Code.
The principal purpose for this record is:
1. To establish a permanent record that is legally recognized as prima facie evidence of the facts stated therein for each
death occurring in the State of California.
2. To provide information, to health authorities and other qualified persons with a valid education or scientific interest, for
demographic and epidemiological studies for health and social purposes.
3. To provide information to the National Center for Health Statistics for compiling national statistical reports, and to state
and federal agencies for file clearance purposes.
4. To provide individuals with certified copies from the records to serve their personal needs, such as applying for social
security or death benefits.
Individuals have the right to review their own records in accordance with the Information Practices Act and University policy.
The record shall be open for examination during regularly scheduled office hours, except when access is specifically prohibited
by statute or regulations.
The State of California Health and Safety Code Section 7054.6, 7117 and 10376, and related provisions in the Civil Code,
Code of Civil Procedure, and Government Code, authorize maintenance of this information. The director responsible for
maintaining the information contained on this form is the Body Donation Program Director, University of California San Diego,
School of Medicine, 9500 Gilman Drive, MC 0627, La Jolla, CA 92093.
FEDERAL
Pursuant to the Federal Privacy Act of 1974, you are hereby notified that disclosure of your social security number is mandatory.
Disclosure of the social security number is required pursuant to the regulations of the State Registrar of Vital Statistics. The
social security number is used to verify your identity.
HIPAA (Health Insurance Portability and Accountability Act) laws and how they relate to the reporting of vital event records.
The information necessary to complete the Certificate of Birth and Certificate of Death is required by California State law
(Health & Safety Code Sections 102425 and 102875 respectively). The Privacy Rule permits covered entities to disclose PHI
(Protected Health Information), without authorization, to public health authorities or other entities that are legally authorized
to receive such reports for the purpose of preventing or controlling disease, injury, or disability. This includes the reporting of
disease or injury and reporting of vital event records, such as births and deaths (Reference 45 Code of Federal Regulations
(CFR) Section 164.512).
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Donor Application UCSF Willed Body Program (University of California, San Francisco)

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Completed 17 September 2020

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