DISTRICT TWELVE MEDICAL EXAMINER
    MANATEE COUNTY FACILITY

    CONSENT FOR RELEASE OF BODY OF DECEASED

    THE MEDICAL EXAMINER OF DISTRICT TWELVE IS HEREBY GIVEN PERMISSION TO DELIVER THE BODY

    OF:

    (Name of Decedent)

    TO: Going Home Cremation Services 941-320-1179

    To undersigned represents:

    To the best of my knowledge, the deceased during his lifetime made no indications contrary to the permission I have given for disposition of the body of the deceased.

    To the best of my knowledge, there is no opposition to the permission I have given for disposition of the body of the deceased by any person who precedes me in legal priority for consent.

    I hereby release the Manatee County Medical Examiner Facility and the District Twelve medical Examiner, there agents, employees or representatives, from any liability which may arise as a result of the release of the above named decedent to me

    Date: ,20

    Consent Signature
    Witness
    Print Name
    Witness
    Relationship

    PRIORITY OF CONSENT:

    • 1. Spouse
    • 2. Adult Son or Daughter
    • 3. Wither Parent of Decedent
    • 4. Adult Brother or Sister
    • 5. Other Blood Relatives
    • 6. Personal Representative of Decedent’s Estate
    • 7. Judicially Appointed Guardian

    Please fax back: 941-320-1179 _ Med.Exam
    Or: 727-934-1529 _ Funeral Home