One of Florida's Most Respected & Trusted Cremation Service

MEDICAL EXAMINER FORM

CENTERAL FLORIDA'S MOST RESPECTED

COUNTY OF VOLUSIA DEPARTMENT OF PUBLIC PROTECTION OFFICE OF THE MEDIAL EXAMINER

1360 Indian Lake Road, Daytona Beach, FL 32124 (386)258-4060 FAX (386) 258-4061 www.volusia.org

REQUEST FOR RELEASE OF BODY TO FUNERAL HOME & REMOVAL AUTHORIZATION REQUEST

1. Complete this form in its entirety, making certain that the NAME OF DECEASED is spelled exactly as the family wishes it to appear on the Death Certificate.

2. The Volusia County Medical Examiner's Office will telephone you when the body is ready to be released. The person(s) picking up the body on your behalf will need to show identification at the front office before the body will be released from the morgue.

3. By submitting this form, the funeral director stipulates he/she has been working with the decedent's legal next of kin or authorized representative regarding final arrangements.

4. FAX this completed form, AS SOON AS POSSIBLE, too (386)258-4061.

FIRST & LAST NAME of the Deceased

DATE OF DEATH

AGE

RACE

SEX

NAME OF NOK AUTHORIZING REMOVAL

RELATIONSHIP

SIGNATURE

NAME OF FUNERAL HOME: JUST4CREMATION.COM. LOCATED AT: 120 East New York Ave. Suite FL, Deland, FL 32724.

PHONE: 386-456-4444 NAME OF TRANSPORT AGENCY: JUST4CREMATION.COM PHONE: 386-456-4444

NAME OF PERSON(S) PICKING UP BODY

Date

SIGNATURE

M.E. STAFF SIGNATURE

M.E. CASE #

Date

PERSONAL EFFECTS YES or NO

DEATH CERTIFICATE YES or NO

Thank you for filling out the Medical Examiner Form.

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