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#DCs___Date___Zucker School of Medicine at Hofstra/Northwell Whole Body Anatomical Gift Program Statistical Information Sheet for the Completion of Death Certificate (Please print or type) Donor Name (First, Middle, Last)___Social Security # ___/___/___ Aliases or AKAs ___ Usual Residence___Apt___M R O F ECity___State___Zip Code___ Telephone #___ ___ ___ email address___ Date of Birth/Race___/Birthplace (City/County, State, or Foreign Country)Veteran of U.S. Armed Forces (Y/N)___

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The Zucker School of Medicine is a medical school located in New York that is part of the Northwell Health system. It focuses on training future healthcare leaders through innovative education and research.

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