Authorization to Relinquish Rights for Personal Effects

Authorization to Relinquish Rights for Personal Effects

The Delaware County Medical Examiners Office
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, am the next-of-kin or closest relative.
Select One*

I agree to pick up the decedent’s personal effects at the DELCO MEO located at 340 N. Middletown Road Media PA Bldg. 19 (Fair Acres)I am unable to receive the personal effects of the decedent listed above and do not wish to undertake the responsibility of receiving the personal effects.
I agree to pick up the decedent’s personal effects at the DELCO MEO located at 340 N. Middletown Road Media PA Bldg. 19 (Fair Acres)I am unable to receive the personal effects of the decedent listed above and do not wish to undertake the responsibility of receiving the personal effects.
Select One*

I hereby authorize for the decedent’s personal effects to be turned over to __________________________________.I hereby authorize the Delaware County Medical Examiner’s Office to arrange for proper disposal of the decedent’s personal effects at county expense.
I understand that any present or future claims to the possessions of the above-named decedent have been waived and do not hold the Medical Examiner’s Office liable.
I hereby authorize for the decedent’s personal effects to be turned over to __________________________________.I hereby authorize the Delaware County Medical Examiner’s Office to arrange for proper disposal of the decedent’s personal effects at county expense.
Decedent’s personal effects to be turned over to*
Signature*

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