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University at Buffalo
School of Medicine and Biomedical Sciences
Department of Pathology and Anatomical Sciences
Anatomical Gift Program
225 Farber Hall, Rm.. 225
3435 Main Street
Buffalo, NY 14214-3000

 Telephone: 829-2913   Fax: 716-829-2915
NEXT OF KIN CHANGE REQUEST

Please notify our office if your next of kin changes so that we may send you an updated wallet card.

To change your designation , please complete the following information and return or fax this form to the address shown above.
Donor Information:
DONOR’S NAME:
DONOR’S ADDRESS:
Next of Kin:
NAME:
COMPLETE ADDRESS:
RELATIONSHIP:
TELEPHONE NO: