HILLSBOROUGH COUNTY MEDICAL EXAMINER DEPARTMENT
    11025 46th Street North Tampa, FL 33617
    PHONE = 813-914-4567          FAX = 813-914-4596

    PERMIT FOR RELEASE OF BODY DIST 13

    I CERTIFY TO THE MEDICAL EXAMINER THAT, PURSUANT TO SECTION 497.005(39), FLORIDA STATUTES, IM THE NEXT-OF-KIN OF THE DECEASED NAMED-BELOW, OR OTHER LEGALLY AUTHORIZED PERSON, AND I ASSUME FINANCIAL RESPONSIBILITY FOR THE DISPOSITION OF THE BODY OR REMAINS OF THE DECEASED NAMED-BELOW AND DIRECT THE MEDICAL EXAMINER TO RELEASE THE BODY OR REMAINS AND PERSONAL EFFECTS OF THE DECEASED NAMED-BELOW:

    PRINTED NAME OF DECEASED: 

    (AGE:    SEX:    SOC. SEC. #: 

    TO THE FOLLOWING FUNERAL HOME/DIRECT DISPOSER: 

    PHONE # OF FUNERAL HOME/DIRECT DISPOSER: 

    Signature of Legally Authorized Person
    Assuming Financial Reponsibility
    Date
     
    Printed Name of Legally Authorized Person
    Relationship to Deceased

    ADDRESS: 

    Witness Signature
    Print Witness's Name
    Date Witnessed
    By claiming the Deceased's body or remains from the Medical Examiner's facility, the above-named funeral director or direct disposer hereby certifies that the Deceased's body or remains are not unclaimed and agrees that in the event the above-named legally authorized person fails to assume financial responsibility for the disposition of the Deceased's body or remains, such funeral director or direct disposer assumes financial responsibility for disposition of such body or remains pursuant to Section 497.005(39), F>S and acknowledges that Hillsborough County has no obligation under Part II of Chapter 406, F.S to dispose of the Deceased's body or remains as unclaimed, and that Hillsborough County will neither accept return of ther Deceased's body or remains, nor assume financial responsibility for disposition of the same

    Signature of Funeral Director or Direct Disposer
    Date

    Funeral Home Notified That Body is Ready for Release on  at     CONTACT NAME: