BROWARD COUNTY AUTHORIZATION FOR RELEASE AND REMOVAL

Office of Broward County Authorization For Release and Removal Medical Examiner and Trauma Services 5301 S.W. 31 Avenue Fort Lauderdale, Flenda 33312-6619. 954-357-5200 Records FAX 954-327-6581 TTY 954-357-6100
Authorization for Release and Removal
Decedent
Name:
Date of Death: *

Month Day Year
Date
Legally Authorized Person
Name:
Relationship to Decedent:
Telephone Number:
Address:
Funeral Facility
Name:
Telephone Number:
Address:
Witness of Signature
Name:
Telephone Number:
BY SIGNING BELOW, I CERTIFY THAT I AM THE "LEGALLY AUTHORIZED PERSON AS DEFINED BY FLA. STAT. $497.005-39 AND DO HEREBY AUTHORIZE THE BROWARD COUNTY MEDICAL EXAMINER TO RELEASE THE REMAINS OF THE ABOVE NAMED DECEDENT TO THE ABOVE NAMED FUNERAL FACILITY
Signature of Legally Authorized Person

Clear
Date

Month Day Year
Date
Signature of Witness

Clear
Date

Month Day Year
Date
ALL FIELDS ARE REQUIRED TO BE FILLED OUT TO COMPLETION INCOMPLETE OR ILLEGIBLE RELEASE AUTHORIZATIONS WILL NOT BE ACCEPTED BY THE MEDICAL EXAMINER'S OFFICE "VERBAL" AUTHORIZATIONS WILL NOT BE ACCEPTED.
Should be Empty:

Authorization for Release and Removal