OFFICE OF THE DISTRICT MEDICAL EXAMINER
    District 22, State of Florida
    Charlotte County
    18130 Paulson Drive
    Port Charlotte, FL 33954
    (941) 625-1111

    District Medical Examiner
    R.H.Imami, M.D., Ph.D.
    Foraneie Odentotogist
    Judith Y. Marshal, D.M.D.

    AUTHORIZATION FOR RELEASE OF BODY BY MEDICAL EXAMINER

    Date 

    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)