san bernardino county coroner release

San Bernardino County Sheriff-Coroner Department

CORONER DIVISION ORDER FOR RELEASE
Order for the release of the body of:
Name
Date

MonthDayYear
Date
AKA (also known as)
"WARNING: The person signing this Order for Release is liable for all damages caused by any untruthful statements contained in this document (Health and Safety Code Section 7110 It is also a criminal offense to knowingly file a false statement with a government agency (Penal Code Section 115 and 470

I certify that, pursuant to Section 7100, Health and Safety Code and 27491.3 of the Government Code of the State of California, it is my legal right to select any funeral director or disposition service. Therefore, upon completion of your investigation of the death of the deceased, please release the body and the personal property of the above deceased to the custody of:
Name of Next of Kin
Relationship
Signed

Clear
Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Telephone
Reason for handling if not next of kin
bearing no full relationship to the above-named deceased, having executed the above authorization do hereby assume responsibilities for the cost of all funeral services in connection therewith of the above-named funeral director.
Witness
Address
City
Telephone
Please enter a valid phone number.
Signed

Clear
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
FUNERAL DIRECTOR DISPOSITION SERVICE

Acting as a representative of the firm of
Address
175 SOUTH LENA ROAD, SAN BERNARDINO, CA 92415-0037 RELEASE HOURS: MONDAY - FRIDAY, 0900 - 1400 HOURS

RELEASING OFFICER FAX # (909) 386-8025 OR (909) 387-2989
Should be Empty: