Human Remains Release Authorization Form
Complete this form to provide the required release authorization details, recipient information, and sign-off for the transfer of human remains. Keep the title exactly as shown throughout the form.
Decedent and Release Details
Decedent's Full Legal Name
*
First Name
Middle Name
Last Name
Date of Passing
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Passing or Holding Facility
*
Authorizing Person or Organization
*
Release Authorization Status
*
Please Select
Authorized to Release
Pending Verification
Not Authorized
Other
Recipient and Arrangement Information
Receiving Funeral Home / Crematory / Transport Provider Name
*
Contact Person Name
*
First Name
Middle Name
Last Name
Business Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Business Email Address
example@example.com
Intended Release Destination / Arrangement Location and Special Handling Instructions
Verification and Signature
Authorized Signer Full Name
*
First Name
Middle Name
Last Name
Title or Role
*
Signature
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: