OFFICE OF THE DISTRICT MEDICAL EXAMINERDistrict 22, State of FloridaCharlotte County18130 Paulson DrivePort Charlotte, FL 33954(941) 625-1111District Medical ExaminerR.H.Imami, M.D., Ph.D.Foraneie Odentotogist Judith Y. Marshal, D.M.D.AUTHORIZATION FOR RELEASE OF BODY BY MEDICAL EXAMINERDate NAME OF LICENSED FUNERAL OR DIRECT DISPOSER ESTABLISHMENT:(Print Name)(City, State)Funeral or Direct Disposer Establishment Phone: # Funeral or Direct Disposer Establishment License # I,(Print Name)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:(Print Name)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).Signed: Printed Name: Address: City, State, Zip Phone No. Signed in the presence of and approved by: (Signature of Licensed Funeral Director Or Direct Disposer)