Dna Testing Request Form printable pdf download

Dna Testing Request Form

Mail request to:

Utah Office of the Medical Examiner

4451 South 2700 West

Taylorsville, Utah 84129

DNA Testing Request Form*

Name of the Deceased: ________________________________________

DOB: _____________________

DOD:________________________

OME Case Number (if known):__________________________________

This instrument authorizes you to furnish and release to:

Testing facility: ______________________________________________

Address: ____________________________________________________

City, State, Zip Code: __________________________________________

□

DNA samples for the purpose of establishing paternity.

□

Other: _______________________________________________________________

Person authorizing request: _____________________________________

Statutory relationship to the deceased

:__________________

per UCA 24-6-7(3)

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)

* A $25 dollar processing fee must accompany request. Make checks payable to

the Utah Medical Examiner’s Office.

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.

Dna Testing Request Form