ANATOMY BOARD OF MARYLAND

MARYLAND DEPARTMENT OF HEALTH
655 WEST BALTIMORE STREET – ROOM B-026
BALTIMORE, MD 21201

ANATOMICAL GIFT: BODY DONATION
RESCIND BODY REGISTRATION

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

Please print form and mail back to address above. No electronic signatures will be accepted. Your original donor form will be returned within 30 days.