Iowa Office of the State Medical Examiner
Department of Public Health
2250 South Ankeny Blvd.
Ankeny, IA 50023-9093
Phone: 515-725-1400
FAX: 515-725-1414
MEDICAL EXAMINER EMBALMING CERTIFICATE
County of __________________________________
Under the provisions of Chapter 331, of the Code of Iowa, I hereby certify that on
(date)_____________________,
I viewed the body and made an investigation of the death of
(Name of Decedent)_________________________________
(Age)__________________
(Sex)__________________
who died on (date)_____________________ at
(Street & No. or Rural Route)______________________________________
(City & State)___________________________________
(County)_______________________________________
and herewith give my permission to
(Embalmer)_____________________________________
(City & State)_________________________________
to embalm the body of the above-named decedent.
Name of Medical Examiner___________________________________________
Signature of Medical Examiner______________________________________
City & State____________________________________
County________________________________________
Date__________________________________________
Note: This certificate must be accompanied by permission of the family, or evidence that a diligent search was made to find the family, prior to embalming.
One copy each to the embalmer and county medical examiner.
Form ME-2 (11/05)
