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Willed Body to Science Self Consent Form BIOLOGICAL RESOURCE CENTER OF ILLINOIS LLC 9501 W. Devon Avenue Suite 505 Rosemont, IL 60018 (847)698-5800 – Main (877)698-5855 – Toll Free (847)698-5803 – Fax

I, ___________________________________________________________________________________________________________________ (Pre-Registered Donor’s Printed Name) hereby bequeath my body, upon confirmed death to Biological Resource Center LLC (BRC) for educational and/or scientific research purposes. I understand that Biological Resource Center LLC will be responsible for any costs directly related to the donation. I understand the nature of the anatomical recovery procedures and authorize Biological Resource Center LLC to dissect and/or disarticulate my body as needed to maximize the use of my body for multiple educational or scientific research purposes. I understand that the universities, organizations or institutions using the recovered specimens of my donated body have been screened for educational or scientific merit and that their “for profit” or “non-profit” corporate status has no bearing concerning their acceptance or denial for distribution of these specimens by Biological Resource Center of Illinois LLC I understand that Biological Resource Center of Illinois LLC will treat my body with dignity and respect within the confines of the above stated uses. *RELEASE AUTHORIZATION* I authorize Biological Resource Center of Illinois LLC to take charge of the arrangements for the donor and I authorize the release and removal of the remains to Biological Resource Center of Illinois LLC for the purpose of whole body donation to science. I authorize Biological Resource Center of Illinois LLC to draw a blood specimen from my body, following my death, for infectious disease testing. These infectious disease tests will include, but are not limited to, testing for HIV/AIDS and viral hepatitis. I authorize Biological Resource Center of Illinois LLC to obtain pertinent medical and social history and/or serological test results whether obtained before or after the death occurred, from any family member, friend, physician, nurse practitioner, medical facility, hospital, or procurement organization to be used as Biological Resource Center of Illinois LLC deems necessary to screen my body for any infectious disease and to determine the suitability of my body for educational or scientific purposes. I understand that all medical information or serological test results will be held in strictest confidence and that all specimens will be coded to maintain the anonymity of the donor in compliance with all state and federal laws. I am making this gift freely and voluntarily, without obligation of any kind on the part of the recipient organization and I understand that there will be no compensation or reward given to me or to my family. I authorize Biological Resource Center of Illinois LLC to cremate the portion of my body not used for educational or scientific research purposes using the services of a licensed crematory. I understand that specimens distributed to educational or scientific institutions will be either medically cremated subject to applicable law and not returned to anyone or returned to Biological Resource Center of Illinois LLC and cremated with other donated specimens and then be buried in the Biological Resource Center’s Memorial Garden. I hereby agree to hold harmless Biological Resource Center of Illinois LLC, Biological Resource Center of Illinois LLC employees, any funeral director or their agent, any funeral home or crematory, Biological Resource Center of Illinois LLC human tissue users or sources from any loss or damage, including incidental and consequential damage, that it incurs while Biological Resource Center of Illinois LLC acts in good faith. Do you wish to have your family or friend receive correspondence from BRC regarding the benefits of the donation to the community? Yes please send my family this information No, I prefer that my family not hear about the benefits of this donation

Once you have been qualified for our program, we guarantee you will be accepted at the time of death.

BRCIL Self Consent Form Version 2013.1

DONOR NUMBER___________________________________________ (OFFICIAL USE ONLY)

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Willed Body to Science Self Consent Form

I represent and warrant to Biological Resource Center of Illinois LLC that: 1.) I have no written documentation that I objected to any type of tissue donation; 2.) I will not receive compensation of any kind; 3.) I will make my appropriate family members aware of my decision to donate. X_______________________________________________________ (Signature of Pre-Registered Donor)

X________________________________________________ (Signature of Witness – Must Be Age 18 or Older)

________________________________________________________ (Printed Name of Pre-Registered Donor)

_________________________________________________ (Printed Name of Witness)

________________________________________________________ (Donor’s Address)

X________________________________________________ (Signature of 2nd Witness)

________________________________________________________ (City, State and Zip Code) Donor’s Phone No. (

)_______________________

_________________________________________________ (Printed Name of 2nd Witness) _______________________________________________________ (EMAIL)

______/_________/____________ _____________ am / pm (Date Consent Signed) Time

FOR DEATHS IN COOK COUNTY, ILLINOIS ONLY I, __________________________, hereby certify that I am the closest living relative or next of kin of ____________________________________, deceased. I further certify that no other relative or party interest has objected to this cremation. Signature ________________________________ Address _________________________________

NOTARY PUBLIC SECTION (Affix Notary Seal Here) Subscribed and sworn before me this

City/State/Zip _______________/_____/_______

___________ day of ___________, 20____

Telephone ________________________________

Sign _______________________________

Do you wish to have cremated remains (Pick One): Returned to the next-of-kin (Fill out Name and Address Below)? Buried in the BRC Memorial Garden at Elm Lawn Cemetery? Returned to another person (Fill out Name and Address Below)?

Elm Lawn Cemetery 401 E Lake St Elmhurst, IL 60126 PH. (630) 833-9696 FX. (630) 833-9697

___________________________________ ________________________________ Cremated Remains Recipient Phone Number ___________________________________ ________________________________ Address City, State and Zip Code

BRCIL Self Consent Form Version 2013.1

DONOR NUMBER___________________________________________ (OFFICIAL USE ONLY)

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