OFFICE OF THE DISTRICT MEDICAL EXAMINER
District 22, State of Florida
18130 Paulson Drive
Port Charlotte, FL 33954
District Medical Examiner
R.H.Imami, M.D., Ph.D.
Judith Y. Marshal, D.M.D.
AUTHORIZATION FOR RELEASE OF BODY BY MEDICAL EXAMINER
NAME OF LICENSED FUNERAL OR DIRECT DISPOSER ESTABLISHMENT:
Funeral or Direct Disposer Establishment Phone: #
Funeral or Direct Disposer Establishment License #
a legally authorized person as defined by Florida Statutes 497.005(43) do hereby authorize the Medical Examiner's Office, District 22 - Charlotte County, Florida to release the body of:
To the above named funeral or direct disposer establishment, after the Medical Examiner has completed and concluded his or her official duties with respect to the body of the deceased, with the understanding that the Medical Examiner's Office is in no way responsible for any of the costs or charges associated with final disposition of the body as defined in F.S. 497.005(35).
City, State, Zip
(Signature of Licensed Funeral Director Or Direct Disposer)