The following portion of the Certificate of Death must
be completed by the nearest relatives. Please print this form and
complete each box accurately and legibly. Coroner or Doctor will
complete and certify the cause of death.
PLEASE COMPLETE THE FOLLOWING INFORMATION
I HEREBY DECLARE that I have the authority and hereby
authorize RELEASE from place of death
My Name (Printed) _________________________________________ Relationship:____________________
City: ____________________________________ State: ________________________ Zip:_______________
My telephone: _______________________________ Other telephone: _______________________________
( ) I will pay for services by
credit card, and provide card number and expiration date by telephone.
Witness: _______________________________________________________ Date: _____________________