Medical Remains Release Consent Form

Medical Remains Release Consent Form
Use this form to request release of medical remains and provide the details needed for authorized transfer.
Decedent Information
Decedent's Full Name
First NameMiddle NameLast Name
Date of Death
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Location of Death or Current Holding Facility
Reference or Case Number
Requester / Authorized Person Information
Full Name
First NameMiddle NameLast Name
Relationship to Deceased
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Role / Authority to Request Release
Release Destination and Handling Instructions
Destination Name
Destination Contact Person
First NameMiddle NameLast Name
Destination Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Transfer Method
Other
Preferred Pickup / Release Date and Time
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
Special Handling Instructions
Consent and Release Acknowledgment
Signature
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