(AFS) Please authorise us to bring your loved one into our care.

Please authorise AFS to bring your loved one into our care.

We know that this is a hard time, we will make things as smooth as possible for you.
Please accept our heartfelt condolences as you proceed to fill out the form.

This form is to be completed by the Executor or Next of Kin.
The Name of the Recently Deceased.

First NameLast Name
The Date of Birth of the Recently Deceased

DayMonthYear
Day Month Year
Which Hospital is the person in. PLEASE FILL IN THE FULL NAME OF THE HOSPITAL.*

Full Name of the Hospital

Street Address

CityState / Province

Postal / Zip Code
PART A: To be completed by the Executor or Next of Kin
Name

Your Given Name (The executor or next of kin)Family Name
Address
Your residential address
Contact Phone Number
I (print name)
give authority to (Funeral Director)
to collect the body of (name of deceased)
Relationship to Deceased
If nominated as a delegate of the Executor/Next of Kin, please provide details
I confirm that I have full and proper authority to permit the facility to release the body of the above named deceased person to the funeral director on this form.
Signature*

Clear
Date

DayMonthYear
Date
PART B: To be completed by Funeral Director (Where a person collecting the body is not a funeral director or acting on behalf of the coroner, please contact the Public Health Unit to confirm whether all necessary approvals have been obtained)
AUTHORITY TO COLLECT DECEASED

Please Do Not Edit anything in the section below.
Funeral Company Name
Address
Transfer Company (if applicable)
Contact Person
Email
example@example.com
Phone Number:
Date

DayMonthYear
Date
Signature

Clear
Agnee Reference Number
Should be Empty:

Please authorise AFS to bring your loved one into our care.

AUTHORITY TO COLLECT DECEASED