ME-5 Cremation (Computer Ready)

Date: 
05/05/2015
Document Text Version

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

CREMATION PERMIT BY MEDICAL EXAMINER

Under the provisions of Chapter 331 of the Code of Iowa**, I hereby certify that I investigated the death of the following (PLEASE COMPLETE THIS ENTIRE FORM):

Name:_________________________________________________

Sex:_________________

Age:_________________

Date of Birth:____________________________

Date and Time of Death:____________________________

If Found, Date and Time:___________________________

Place of Death (Address):________________________________________________

City, State, Zip:________________________________________________________

Cause of Death:__________________________________________________________

Due to:__________________________________________________________________

Due to:__________________________________________________________________

Other Significant:_______________________________________________________

Manner of Death (Circle One):

Natural      Homicide      Accident      Suicide      Undetermined      Pending

Medical Examiner Case (Yes or No):_____________

Autopsy (Yes or No):_____________

Body viewed** (Yes or No):_____________

County of Death ________________________________________

Physician signing death certificate (Print or Type):_____________________________________

Inasmuch as my investigation did not disclose suspicious circumstances or other reason to investigate this case further under the Medical Examiner Statutes, I herewith give my permission to the following crematory/funeral home to cremate the body of the above-named decedent:

Name of Funeral Home/Crematory:____________________________________________________________________

Funeral Home Address:_____________________________________________________________________________

City, State, Zip:____________________________________________________________________________________

Name of Medical Examiner (Print or Type):_______________________________________________________________

Signature:_________________________________________________________________________________________

Medical Examiner Address:___________________________________________________________________________

City, State, Zip:_____________________________________________________________________________________

Date of Examination / Investigation______________________________________

**If the death occurred in a manner specified in Iowa Code section 331.802(3), a medical examiner must view the body, make personal inquiry into the cause and manner, of death, and ensure that all necessary autopsies or post-mortem examinations have been completed prior to issuing a cremation permit.  For deaths other than those specified in section 331.802(3), chapter 331 contains no requirement that a medical examiner view the body prior to issuing the cremation permit.

Form ME-5 (11/05)

Printed from the Iowa Office of the State Medical Examiner website on June 05, 2020 at 4:45pm.