WILLED BODY DONATION PROGRAM POLICY

The donation of a person’s body after death is a tremendous gift. We are grateful for everyone who expresses an interest in body donation. Please read the following policies of the Southeast Texas Applied Forensic Science Facility. After reading the information, please sign and date.

1. Unlike medical schools, we do not return remains to a family, unless pre-arranged. The skeletal remains are a very importantcomponent to our research and teaching programs in forensic science.

2. The Southeast Texas Applied Forensic Science Facility reserves the right to decline donations of individuals who have someform of infectious disease such as HIV, tuberculosis, hepatitis of any kind, or antibiotic resistant infections such as MRSA,even if contracted after donation is arranged.

3. Donors with an infectious disease who still wish to donate may do so by choosing to have their remains cremated. Cremainsprovide an invaluable learning resource. People choosing this option should contact us prior to making arrangements. Thisallows us to work with the crematory involved to ensure the remains are not pulverized. The family must assumeresponsibility for the cost of cremation.

4. We will arrange transportation to our facility if the deceased is located within the state of Texas and within 250 miles ofHuntsville. Outside of Texas or more than 250 miles from Huntsville, the donor or donor’s family must make arrangements forthe transportation of the body.

5. We are unable to transport from a private residence. The donor’s family must arrange for transportation and assumeresponsibility for the cost. We will transport a body from a hospital, funeral home, forensic center, or some healthcare facilitiesthat are within the geographic limits stated above.

6. Signed donation documents or releases must be executed prior to transportation to the Southeast Texas Applied ForensicScience Facility. These documents may be a faxed copy, but the original must be sent as soon as possible. Your donationpaperwork will not be complete until originals are returned.

7. For processing of the death certificate a valid social security number is required. The Southeast Texas Applied ForensicScience Facility cannot accept donors without a valid social security number (required on the Body DonationQuestionnaire form).

SOUTHEAST TEXAS APPLIED FORENSIC SCIENCE FACILITY

SAM HOUSTON STATE UNIVERSITY

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8. Living donor needs to be completed and returned to the Southea st Texas Applied Forensic Science Facility in order for a fileto be established. Changes of address o r medical status should be sent to keep donor files up to date.

9. All donor paperwork needs the information and signature of two witnesses to verify the donor’ s/next of kin/executorssignature, but does not need to be notarized. Texas law requires two witness signatures.

10. All information provided on the Body Donation documents is kept confidential.

12.

I have read, understand, and agree to the policy of the Southeast Texas Applied Forensic Science Facility’s Willed Body Donation Program.

________________________________ Signature of Donor/Next of kin/Executor

__________________________________________________________________________ Street Address, City, State, Zip code, Phone number with area code, E-mail (optional)

___________________Date

_______________________________________________ ______________________________________________ Printed Name of Witness Signature of Witness

___________________________________________________________________________________________________ Street Address, City, State, Zip code, Phone number with area code, E-mail (optional)

__________________________ Date

_______________________________________________ ______________________________________________ Printed Name of Witness Signature of Witness

___________________________________________________________________________________________________ Street Address, City, State, Zip code, Phone number with area code, E-mail (optional)

__________________________ Date

TWO WITNESSES OF THE NEXT OF KIN/EXECUTOR'S SIGNATURE ARE REQUIRED BY LAW

___________________________________________ Printed Name of Donor/Next of kin/Executor

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11.

If you have any questions or concerns that have not been addressed in this policy letter, pleas e feel free to contact us at

936-294-2310 or stafs@shsu.edu.

A $100 fee will be charged for a donation weighing 300-400lbs and $200 for donations weighing 400-500lbs. Donations over 500lbs cannot be accepted. Payment must be received with paperwork prior to donation pick up. Please make checks payable to Sam Houston State University.

Under Texas law, donations of a body may be made A. During the life of the donor by the individual donor, the donor’s parents if a minor, the donor’s guardian, and/or the donor’s medical agent under power of attorney by providing the requisite paperwork (included below) for donation of the remains. B. After demise - the next of kin or class of individuals listed in Texas Health and Safety Code Section 692A.009 may provide the requisite paper work to donate remains, so long as that individual knows of no objection by another individual also entitled to make such donation.

13.

Witnesses to the signiture of the donor/next of kin/executor please sign below____________________________________________________________

I, __________________________________________, do hereby dispose of and give my body, after my death, to Sam Houston State

University, for the use by the Southeast Texas Applied Forensic Science Facility, or its designee, for educational and research

purposes. I request, authorize, and instruct my surviving spouse, next of kin, executor or the physician who certifies my death to notify

the Southeast Texas Applied Forensic Science Facility at Sam Houston State University (telephone: 936-294-2310) immediately after

my death of the availability of my body.

Witness my hand and seal this ________ day of ____________________, in the year of 20_______, at ________am/pm (circle one). (month)

_____________________________________________________________________________________________ Donor’s Address

_____________________________________________________________________________________________ Donor’s City, State, Zip Code, Phone #, E-mail (optional)

__________________________________________________ Donor’s Signature

__________________________________________________ Donor’s Printed Name

On this ________ day of ______________________, in the year of 20_______

______________________________________________________________________ signed this Body Donation (Donor’s Name)

Document in our presence and we, as attesting witnesses, and in his/her presence and in the presence of each other have also signed

this document.

WITNESSES:

Printed Name _______________________________________Signature_____________________________________________

Address ___________________________________________ Phone ________________________________________

___________________________________________ E-mail ________________________________________

Printed Name _______________________________________Signature ____________________________________________

Address ___________________________________________ Phone ________________________________________

___________________________________________ E-mail ________________________________________

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Witnesses to the signature of the donor please sign below_____________________________________________________________________________________________________________

(month)

SOUTHEAST TEXAS APPLIED FORENSIC SCIENCE FACILITY SAM HOUSTON STATE UNIVERSITY

Living Donor Release Form

WILLED BODY DONATION PROGRAM DONOR FORM

________________________________ ___________________________________ Date Social Security Number

______________________________________________________________________________________________________ Name of Donor (Please Print)

______________________________________________________________________________________________________ Address, City, State, Zip code, Phone number. Email (optional)

The Willed Body Program at Sam Houston State University is recognized by the Anatomical Board of the State of Texas.

It is my wish that at the time of my death my body be made available for teaching and scientific purposes to Sam Houston State University and that it will not be returned to my next of kin or any other recipient without my completion of the Special Disposition of Body Request Form. I understand that the University will pay for transportation of my body as long as it is located within a 250mile radius of Sam Houston State University, Huntsville, Texas 77340.

I understand that the Southeast Texas Applied Forensic Science Facility at Sam Houston State University reserves the right to decline donations. If the Willed Body Program is unable to use my body for these or other reasons, my next of kin must make other final disposition arrangements. The Willed Body Program is not responsible for any costs associated with other necessary arrangements.

At the time of my death, I hereby relinquish all rights and claims regarding my body and direct that by accepting and using my body for teaching and scientific purposes and its subsequent disposition, neither the Anatomical Board of the State of Texas or Sam Houston State University shall incur any liability and no manner of claim shall arise against the Anatomical Board of the State of Texas or Sam Houston State University.

Complaints or inquiries regarding a willed or donated body should be directed to the Secretary-Treasurer of the Anatomical Board of the State of Texas. The name and address of this individual may be obtained from the institution to which the body was delivered or the Texas State telephone directory.

________________________________________ Body Donor Signature

__________________________________________________ _______________________________________________ Witness Witness ___________________________________________________ ________________________________________________ Address Address __________________________________________________ ________________________________________________ City, State, Zip code, Phone number City, State, Zip code, Phone number

_________________________________________ _____________________ _______________________________________________ Name of Next of Kin Relationship to Donor Signature of Next of Kin __________________________________________________________________________________________________________________________________ Street Address, City, State, Zip code, Phone number (area code included)

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SOUTHEAST TEXAS APPLIED FORENSIC SCIENCE FACILITY SAM HOUSTON STATE UNIVERSITY

Body Donation Questionnaire Please complete the following information by filling in the blank and/or circling an option. If you need more space, additional sheets may be attached. Please print all

information. All of the information is confidential.

Full Legal Name _______________________/______________________/_____________ Sex: ___Male___Female Last First Middle (full name)

Social Security #____________-______-______________ Ancestry: Black / Hispanic / White / Other ________________

Date of Birth_______ /_______ / _________ Place of Birth (city/state/county)___________________________________

Current Address ______________________________________________________ City ______________________________State_________ Zip Code______________ Inside City limits Yes __ No __ Mother’s Name (include maiden) ______________________________________________________________________ Father’s Name _____________________________________________________________________________________

Height ________ Weight ________ (Are you estimating height and weight? Yes __ No __ )

Handedness: Right ____ Left ____ Shoe size ________ Blood type _______ Hair Color _________________(natural color)

Marital Status: (circle one) Never Married Married Widowed Divorced Other _______________________________ (Please explain)

Spouse: ___________________ / ___________________ / __________________ Living ___Deceased ___ Unknown ___ Last (include maiden) First Middle

Number of Children: _____ Military Service: Yes __ No __ Military Branch ______________

Military Serial #____________

Highest Education Level (please check one)

Texas Peace Officer Yes __ No __

8th Grade or Less_____ 9th-12th Grade; No Diploma_____ HS Graduate or GED Completed_____ Some College Credit, but not a degree_____ Associate Degree (AA, AS)_____

Bachelor’s Degree (BA, AB, BS)_____ Master’s Degree (MA, MS, MENG, MED, MSW, MBA)_____ Doctorate (PhD, EDD)_____ Professional (MD, DDS, DVM, LLB, JD)_____ Unknown_____

Childhood Socio-Economic Status: (circle one) Lower Lower Middle Middle Upper Middle Upper

Occupation (life-long) _____________________________ Business/Industry _________________________________

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SOUTHEAST TEXAS APPLIED FORENSIC SCIENCE FACILITY SAM HOUSTON STATE UNIVERSITY

SOUTHEAST TEXAS APPLIED FORENSIC SCIENCE FACILITY SAM HOUSTON STATE UNIVERSITY Body Donation Questionnaire (continued)

Full Legal Name _______________________/______________________/_____________

Dental History – Check all that apply ____Extensive dental work ____Most/all teeth Teeth Missing ____Lower dentures: When ____________ ____Bridge ____ Few ____Upper dentures: When ____________ ____Gum Disease ____Many ____Upper and lower dentures: When ___________ ____Dental Disease ____All ____Partial plate ____Other___________________________ ____Braces

Please complete the following information by filling in the blank and/or circling an option. If you need more space, additional sheets may be attached. Please print all information. All of the information is confidential.

Medical History (please indicate the approximate year for each)

____Surgery (general) ______ ____ Infectious disease (TB, HIV, Hepatitis B or C etc.)________________ ____Plastic surgery (indicate type and location)________________ ____Bone fractures (location)_____________________________________ ____Auto accident (traumatic)______ ____Spinal injuries ______ ____Open heart surgery ______ ____ Amputations ______ ____Diabetes ______ ____ Prosthetics _______ ____Smoker – How long?_____________ ____ Alcoholism ______ ____Cancer (type)_________________________________________________________Type of treatment_____________________________ ____ Other (includes childhood disorders) __________________________________________________________________________________ ____________________________________________________________________________________________________________________

Please describe in more detail the above information or any other you think may be important, including current medications, timing of illnesses/injuries, and the location of traumatic injuries your body has endured. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Habitual Activities (i.e. repetitive occupational stresses, such as lifting, jogging, etc.) ________________________________________________ ______________________________________________________________________________________________________________________

Eye Color ____Blue ____Green ____ Gray ____ Brown ____ Hazel ____ Other

Tattoo(s) ____Yes ____ No If yes, please give description(s) and body location(s) ___________________________________________ ______________________________________________________________________________________________________________________

Body Piercing(s) ____Yes ____ No If yes, please give description(s) and body location(s) ___________________________________

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SOUTHEAST TEXAS APPLIED FORENSIC SCIENCE FACILITY SAM HOUSTON STATE UNIVERSITY Body Donation Questionnaire (continued)

______________________________________________________________________________________________________________________

Informant Information (if other than donor) Name _______________________________________ Relationship to donor _____________________________________________________ Address _______________________________________________________Phone number ___________________________________________ City ______________________________________State ______ Zip code _________________ e-mail: __________________________________

Thank you for taking the time to complete this questionnaire. If we can be of further assistance, please feel free to contact us.

Return completed forms to:

Kevin DerrSoutheast Texas Applied Forensic Science Facility (STAFS)

Sam Houston State University College of Criminal Justice

Box 2296 Huntsville, Texas 77341-2296

Phone: 936-294-2310 Fax: 936-294-2311

Email: stafs@shsu.edu

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WILLED BODY DONATION PROGRAM SPECIAL DISPOSITION OF BODY REQUEST FORM

I, ____________________________________, request the remains of _______________________________to be returned to me, the undersigned next of kin__________________________, after completion of scientific and/or teaching purposes. I hereby request and authorize the Southeast Texas Applied Forensic Science Facility at Sam Houston State University to return the remains to the undersigned next of kin via United States Courier to the address below.

As next of kin, I understand that there is a $900.00 charge (or current market rate) for return of remains, and I agree to make

payment or make arrangements for payment prior to return.

The Southeast Texas Applied Forensic Science Facility at Sam Houston State University will contact me when the remains are available. I understand that every effort will be made to comply with the donor’s request. Two years or more after the body is accepted may elapse before I am contacted. I understand that in the event that the Southeast Texas Applied Forensic Science Facility is unable to locate me after written notification by mail, the Southeast Texas Applied Forensic Science Facility will hold the remains for at least ninety (90) days from the first written notification attempt. After the ninety (90) days have elapsed without a response from me, I relinquish my rights to the remains and the Southeast Texas Applied Forensic Science Facility may keep them for scientific or research purposes, only one 6 month extension is permitted.

________________________________________ ______________________ _________________________________ Name of Next of Kin (please print) Relationship to deceased Signature of Next of Kin

___________________________ Date _________________________________________________________________________________________________________ Street Address, City, State, Zip code, Phone number with area code, E-mail (optional)

________________________________________ ________________________________ _________________________ Printed Name of Witness Signature of Witness Date

_______________________________________________________________________________________________________________________________ Street Address of Witness, City, State, Zip code, Phone number with area code

________________________________________________ _______________________________________ ______________________________ Printed Name of Witness Signature of Witness Date

_______________________________________________________________________________________________________________________________ Street Address of Witness, City, State, Zip code, Phone number with area code

I, ____________________________________, DO NOT request the remains of _______________________________to be returned to me, the undersigned next of kin__________________________. I hereby authorize the Southeast Texas Applied Forensic Science Facility at Sam Houston State University to keep the remains.

Complete for instructions on dispotion of remains after research is complete (up to 5 years).

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SOUTHEAST TEXAS APPLIED FORENSIC SCIENCE FACILITY SAM HOUSTON STATE UNIVERSITY

Witnesses to the signature of the donor please sign below_____________________________________________________________________________________________________________

Instructions for Obtaining the Death Certificate

Death Certificates are obtained through the County Clerk’s office in the county of the deceased’s residence.

The Southeast Texas Applied Forensic Science Facility does not issue the death certificate.

Under the Texas State Law a death certificate must be initiated within 10 days from the date of the body’s final

disposition.

STEPS IN THE DEATH CERTIFICATE PROCESS

1. Once the physical body is received we start the death certificate process by entering the deceased’sinformation into the state’s electronic database.

2. This information is electronically sent to the certifying physician/medical examiner, who then completesthe portion concerning cause and manner of death.

3. The death certificate is then sent back to us to verify that all information is correct.4. Once it is verified, the death certificate is sent to the state who then forwards it to the county clerk’s

office.5. The deceased’s death certificate is then available to the family/next of kin. Under normal circumstances

this process takes approximately two weeks.6. The death certificate can be obtained from the county clerk’s office in the county where the deceased

died OR requested online at the Texas Vital Statistics website http://www.dshs.state.tx.us/VS/ underDeath Records.

Regional County Clerk’s Offices Information:

Harris County Clerk Administrative Offices Harris County Civil Courthouse 201 Caroline, Suite 460 Houston, TX 77002 713-755-6411 www.cclerk.hctx.net/

Montgomery County Clerk 210 West Davis (Hwy 105) Conroe, Texas 77301 936-539-7885 www.mctx.org/dept/departments_c/county_clerk/index.html

Galveston County Clerk 600 59th St # 2001 Galveston, TX 77551 (409) 766-2200 www.co.galveston.tx.us/county_clerk/

Walker County Clerk 1100 University Avenue # 209 Huntsville, TX 77340 (936) 436-4972 http://www.co.walker.tx.us/

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SOUTHEAST TEXAS APPLIED FORENSIC SCIENCE FACILITY SAM HOUSTON STATE UNIVERSITY