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)
