Medical Examiner Relinquish Rights Request

Medical Examiner Relinquish Rights Request

The Delaware County Medical Examiners Office
Name of the Decedent*
Case Number of the Decedent*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Name of Next of Kin*

First NameLast Name
Relationship to the Decedent*
Copy of Next of Kin's Driver's License*

Cancelof
Authorization to Relinquish Rights for Disposition
Decedent Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age/Race/Gender/Marital Status*
Date of Death*

MonthDayYear
Date
I Name*, bearing the relationship of Relationship* to the above named decedent, I am the closest next-of-kin/person to him/her. I am unable to bear the financial responsibility for the disposition of the body and know of no other persons who wish to undertake the responsibility for the disposition of the remains.
I hereby authorize the Delaware County Medical Examiner’s Office to arrange for cremation of the remains of the above-named decedent at county expense with the exception being any and all monies recouped from the decedent’s estate may be applied toward the costs of cremation and other related expenses.
I understand that any present or future claims on the body of the above-named decedent have been waived, pursuant to this authorization for cremation.
Signature*

Clear
Should be Empty:

Authorization to Relinquish Rights for Disposition