Authorization For Autopsy - Parkland Health & Hospital System Page 3

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PARKLAND HEALTH & HOSPITAL SYSTEM
Dallas, Texas
AUTHORIZATION FOR AUTOPSY
PLACE EPIC LABEL HERE
Page 3 of 4
T
D
S
H
S
EXAS
EPARTMENT OF
TATE
EALTH
ERVICES
POSTMORTEM EXAMINATION OR AUTOPSY CONSENT FORM
This form is prescribed under Article 49.34 of the Code of Criminal Procedure. Please see the reverse side for further
information regarding the law and the completion of this form.
NAME OF DECEDENT:
DATE OF DEATH
NAME AND TITLE OF PHYSICIAN PERFORMING PROCEDURE:
TEXAS LICENSE NUMBER:
Medical Director of Autopsy or Designee
N/A
NAME OF FACILITY AND DEPARTMENT WHERE THE PROCEDURE WILL BE PERFORMED:
Parkland Hospital, Department of Pathology
The physician may be required to remove and retain organs, fl uids, prosthetic devices, or tissue for
purposes of comprehensive evaluation or accurate determination of a cause of death.
Please indicate which, if any, restrictions or special limitations you would like to make on the procedure:
None. Permission is granted.
Permission is granted for an autopsy with the following limitations and conditions (specify):
____ Exam is restricted to brain and spinal cord
____ Exam is restricted to the chest and abdomen only
____ Exam is restricted to the chest cavity
____ Exam is restricted to the abdominal cavity
____ Other: (Specify)
I authorize the release of the remains to the funeral services provider or person listed below after
examination.
Name of Funeral Service Provider or Person:
Telephone Number:
Specify or state Unknown
Authorizing Individual MUST SIGN
Authorizing Person’s Signature
Date
Authorizing Person’s Printed Name and Relationship to Decedent
Witness’s Signature
Date
Witness’s Printed Name
Warning: It is a felony to falsify information on a Vital Statistics application, record or report. The penalty for knowingly
making a false statement on this form or for signing a form which contains a false statement is 2 to 10 years imprisonment
and a fi ne of up to $10,000. (Health and Safety Code §195.003)
Telephone Consent must be notarized
Form Number: CON006 (Page 3 of 4) Revised Date: 7/11/2012
VS-200 (04/2012)

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