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)
