ME-13 Funeral Home NOK Authorization for Removal

Date: 
06/11/2019
Document Text Version

IOWA OFFICE OF THE STATE MEDICAL EXAMINER
2250 South Ankeny Blvd.
Ankeny, IA
515-725-1400
Fax 515-725-1443

FUNERAL HOME NEXT-OF-KIN AUTHORIZATION FOR BODY REMOVAL
PLEASE PRINT LEGIBLY


Date:
Case #:

DECEDENT
Name (First, Middle, Last):
Date of Death:

NEXT OF KIN
Name (First, Middle, Last):
Phone (Required)(Include Area Code):

DRIVER
Name (First, Middle, Last):
Representing/Authorized By (Name of Entity Removing Decedent from IOSME
Phone (Required)(Include Area Code):

CERTIFICATION
I certify that the above-named funeral home has been selected by the legal next-of-kin to perform services for the above-named decedent.

OR

I certify that the above-named funeral home is doing a trade call and has permission to remove the above-named decedent on behalf of (enter name of funeral home/entity): 

SIGNATURES
REQUIRED - Funeral Home:
Date:
OPTIONAL - Next of Kin:
Date:

Form ME-13 (06/2019)

Printed from the Iowa Office of the State Medical Examiner website on October 29, 2020 at 8:13pm.