Records Request Form printable pdf download

Records Request Form

Mail request to:

Utah Office of the Medical Examiner

48 North Mario Capecchi Dr.

Salt Lake City, Utah 84113

(801) 584-8410

Records Request Form

Name of the Deceased: ________________________________________

DOB: _____________________

DOD: ______________________

OME Case Number (if known): __________________________________

This instrument authorizes you to furnish and release to:

Name: ______________________________________________________

Office: ______________________________________________________

Address: ____________________________________________________

City, State, Zip Code: __________________________________________

The release authorizes you to furnish the following records:

Person authorizing request: ______________________________________

Statutory relationship to the deceased

: __________________

per UCA 24-6-7(3)

Phone number: _______________ Email: _________________________

Signature of Authorizing Person: _________________________________

Date (within 90 days of request): _________________________________

STATE OF [State]

COUNTY OF [County]

Subscribed and sworn before me this ____ day of _____________, 20___.

___________________________________

NOTARY PUBLIC

My Commission Expires: ______________

(SEAL)

The records maintained by the Office of the Medical Examiner are classified confidential and any release

shall be consistent with the provisions of Utah Code Ann. § 26-4-17(3) and (4) (2004) and Utah Admin.

Rule R448-20-4 2000. [rev. 11/2009]

Forms must have original signatures. No photocopies or faxes accepted. Some fees may apply.

Make checks payable to: Utah Medical Examiner’s Office

Records Request Form