Family Request for Autopsy Report (MS Word, Fill-In Enabled)

Date: 
08/01/2019
Document Text Version

Form linked above is in Microsoft Word format and may be typed and printed. 
Please use the above form for mailing or faxing. 
PLEASE NOTE:  You may need to click "Enable Editing" once the form opens on your computer. 
This form must be notarized.
IOWA OFFICE OF THE STATE MEDICAL EXAMINER
2250 South Ankeny Blvd.
Ankeny, IA  50023-9093
Family Request for Autopsy Report
MUST BE NOTARIZED
Autopsy results may be released to the immediate next-of-kin according to Iowa Code 22.7, item 41.
Name of Requestor:
Name of Deceased:
Date of Death:
Relationship to Deceased:
Address to Send Report (For privacy, reports cannot be faxed or e-mailed)
Street:
City/State/Zip:
Phone (Required)(Please include area code):
Was the deceased married at the time of his/her death?     Yes     No
Does the deceased have any children age 18 or older?     Yes     No
Are the parents of the deceased still living?     Yes     No
Does the deceased have siblings age 18 or older?     Yes     No
Signature of Legal Next-of-Kin:
Must Be Notarized
Date:
Acknowledgment
State of
County of
This instrument was acknowledged before me on
Date
By
Signature of Notary
Please mail or fax this form to:
Iowa Office of the State Medical Examiner
2250 South Ankeny Blvd.
Ankeny, IA 50023-9093
Fax: 515-725-1414

Printed from the Iowa Office of the State Medical Examiner website on June 05, 2020 at 5:47pm.