Order For Release Of Remains - County Of San Diego
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1COUNTY OF SAN DIEGO MEDICAL EXAMINER
5570 OVERLAND AVENUE, SUITE 101, SAN DIEGO, CA 92123-1206
PHONE: 858-694-2895
ORDER FOR RELEASE OF REMAINS
TO: MEDICAL EXAMINER, COUNTY OF SAN DIEGO
RE: REMAINS OF ________________________________________________, ME CASE # _____________
I certify that pursuant to the State of California Health & Safety Code, Section 7100, it is my legal right to control the disposition of
the remains referenced above, the location and conditions of interment, and arrangements for funeral goods and services to be
provided. I further certify that I am acting in the capacity of:
Legal Next of Kin__________, OR Executor/Executrix
__________, OR Agent with Durable Power of Attorney for Health Care (must be for Health Care) __________ OR other legal
capacity __________ (please INITIAL the appropriate category). If acting in a capacity other than Legal Next of Kin, I have
attached a copy of the relevant appointing document(s).
I acknowledge that, pursuant to the State of California Government Code Sections 27472 and 54985 and Ordinance No. 10151 of the
Board of Supervisors, County of San Diego, I may be liable for Medical Examiner fees of $280 for transportation ($245) and body
pouch ($35) and agree to pay said fees promptly. _______ (please INITIAL).
Therefore, upon completion of your examination of the deceased please release the remains referenced above to the custody of the
service designated below. If possible please RELEASE _________ OR DO NOT RELEASE_________ (please INITIAL desired
choice) all of the deceased’s personal property in your care with the remains. I understand that personal property can only be released
during regular working hours (M-F 8-5, except holidays).
Print Name of Designated Mortuary, Cremation Society, or other Disposition Service
__________________________________________________
____________________________________
Print Name of Person Signing
Relationship
Signature
Date Signed
__________________________________________________
____________________________________
Mailing Address of Person Signing
Phone #
__________________________________________________
____________________________________
City, State, Zip Code of Person Signing
City, State Where Signed
DECEDENT INFORMATION
Name of Deceased – First (Given)
Middle
Last (Family)
Gender
Date of Death
Date of Birth
Age
Place of Birth
Social Security Number
Race
Marital Status
Occupation
Residence Address:
MEDICAL EXAMINER DEPARTMENT USE ONLY
Manner of Payment
Person Executing This Order For Release ______
Bill Mortuary ______
Mortuary Pre-Pay ______
Active Duty Military ____ PA ____ Under 14 ____ Family Requested Autopsy _____ Other _________________
ME FAS ____________________
Rev. 07/14/2011
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