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I. The Deceased:
Name:______________________________________________
Age__________Sex__________
Marital Status______________ Date of Death_________________ Time of Death____________
Location of Death Pronounced _____________________________________________________
II. The Party Requesting the Autopsy:
Name:________________________________________________________________________
Address:_______________________________________________________________________
______________________________________________________________________________
Phone Number:___________________Relationship to Deceased:_________________________
III. Consent to and Request for Autopsy:
I hereby authorize Private Autopsy Service, LLC, or any other person or persons as it may designate, to perform an autopsy on the
body of the above named deceased. I warrant that I have the legal authority to give consent and to make this request. Organ specimens may be removed and retained for study subsequent to the autopsy which, in the judgment of the physician by whom it is performed, may be necessary to accomplish its purpose. Disposal of specimens shall occur one year from the date of the autopsy, unless directed otherwise, in writing, by the next of kin and shall be handled by standard biohazard technique unless directed otherwise as indicated in the space provided. (Other direction, if any:________________________________) Unless
specifically limited, the autopsy request shall be a complete autopsy including head.
(Limitations, if any:______________________________________________________________)
I understand that the services provided shall not include a review of the medical records, toxicologic analysis or bacteriologic, serologic, virology or any analyses examination.
After the autopsy, I direct the body to be released to: (the Funeral Home of your choice
________________________________________________ )
Date ____________________
Signature ____________________________________________
Witness _____________________________________________
Witness _____________________________________________
Address _____________________________________________
City / State / Zip ________________________________________
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