HILLSBOROUGH COUNTY MEDICAL EXAMINER DEPARTMENT11025 46th Street North Tampa, FL 33617PHONE = 813-914-4567 FAX = 813-914-4596PERMIT FOR RELEASE OF BODY DIST 13I 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 PersonAssuming Financial ReponsibilityDate Printed Name of Legally Authorized PersonRelationship to DeceasedADDRESS: Witness SignaturePrint Witness's NameDate 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 sameSignature of Funeral Director or Direct DisposerDateFuneral Home Notified That Body is Ready for Release on at CONTACT NAME: