Order For Release County Of Ventura - Medical Examiner-Coroner

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ORDER FOR RELEASE
COUNTY OF VENTURA
Medical Examiner-Coroner
CASE # __________________
I CERTIFY THAT I AM THE NEXT OF KIN PURSUANT TO SECTION 7100, HEALTH & SAFETY
CODE, STATE OF CALIFORNIA, OR AM A RELATIVE ACTING AS THE AGENT FOR THE NEXT
OF KIN AND IT IS MY LEGAL RIGHT TO NOMINATE A FUNERAL DIRECTOR TO TAKE CHARGE
OF THE BODY OF:
______________________________________________________,
name of deceased
I AUTHORIZE RELEASING THE BODY OF THE DECEASED TO
____________________________________________________________________
name of funeral establishment
─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─
AUTHORIZING PERSON’S INFORMATION:
Print Name _________________________________ Relationship ___________________________
Address __________________________________________________________________________
Telephone Number _______________________
Sign here _______________________________
Date Signed ___________________________
─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─
IF THE AUTHORIZING PERSON IS NOT THE NEXT OF KIN, SIGN ABOVE AND EXPLAIN BELOW
WHY THE NEXT OF KIN IS NOT MAKING THE ARRANGEMENTS:
─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─ ─
WITNESS INFORMATION:
Witness Name___________________________ Witness Signature___________________________ Date____________
__________________________________________________________________
Relation/organization
MEO 01/2012

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