Donor Body Registration – Step 1

We understand this may be a difficult time. Our services are free of charge, and we try to make this process as simple as possible.

Please complete the following information for your loved one or a patient in your care.

This information is needed to be considered for The United Tissue Networks Whole Body Donation Program. After you complete it, a Donation Coordinator will reach out to complete this process. This information is important and needed before any case can be reviewed.  

This application will take about 20 minutes to complete. Although not required, we recommend watching the videos for each section. They will help answer many commonly asked questions.

Please note that we are only accepting in the states of Arizona, Nevada, and Florida at this time.

The information provided will assist UTN in completing the required end-of-life documents, including the Death Certificate Worksheet. If you need to speak with a representative at any time, please call 877-738-6111 or email donorinfo@unitedtissue.org.

"*" indicates required fields

Please complete the following form fields:

Is the donor in the states of Arizona, Florida, or Nevada?*

Yes

No

THANK YOU.

Thank you for your interest in Whole Body Donation with Cremation. We sincerely appreciate your thoughtful consideration of this noble option.

We are unable to accept the donation based on the information provided. We sincerely thank you and our thoughts are with you as you navigate this challenging journey. If you have any questions or would like to speak with a representative, please do not hesitate to reach out, 877-738-6111 or via email at donorinfo@unitedtissue.org

Contact Information of the Person Completing this Form

Full Legal Name*

Address*

Street Address City/Town State StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip

Email*

Phone*

What is your relationship to the donor?

SelfSpouseChildSiblingParentGrandparentGrandchildPower of AttorneyOther

Donor Information – Information about the individual interested in whole-body donation.

Name*

First Last

Donor Address*

Same as previous

Street Address State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific

Date of birth*

MM slash DD slash YYYY

Marital status

Primary Physician

Primary Physician Phone

Status of the donor*

Donor is currently living and interested in registering to donate their body to science after their passing.

Donor is currently receiving hospice care or experiencing a terminal illness with limited time remaining.

Donor has passed away.