ANATOMY BOARD OF MARYLAND
MARYLAND DEPARTMENT OF HEALTH
655 WEST BALTIMORE STREET – ROOM B-026
BALTIMORE, MD 21201
It is my desire to rescind by body donation with the Anatomy Board of Maryland. I authorize the Anatomy Board to remove my registration and return my original signature copy form to the address below.
Name: FIRST
LAST
MIDDLE
Address: Street
City
State
Zip Code
Must be signed by the living individual of sound mind, not POA, Guardian, ELECTRONIC etc.
TWO WITNESSES REQUIRED
Name-Please print clearly
Address
Witness 1 Signature
Name-Please print clearly
Address
Witness 2 Signature