RELEASE OF REMAINS AUTHORIZATION

RELEASE OF REMAINS AUTHORIZATION
Name of Hospital:
Address of Hospital
Zip Code of Hospital
State of Hospital
City of of Hospital
1) I certify that I am the next of kin pursuant to Section 7100, of the Health and Safety Code, State ofCalifornia, or a relative acting of the Next of Kin and it is my legal right to designate the above namedMortuary to take charge of the body of:

(1) Certifico ser el familiar más cercano de conformidad con la sección 7100 del Código de Sanidad y Seguridad, en el Estado de California, o el pariente del familiar más cercano, y es mi derecho legal el designar a la funeraria arriba mencionada para que se haga cargo del cuerpo de:
Name of the Decedent
Date of Birth

MonthDayYear
Date
AKA
Date of Death

MonthDayYear
Date
Name of Person Authorizing/Nombre de la Persona Autorizando
Relationship/Relación con el Fallecido(a)
Address
City
State
Zip Code
Phone #
Date

MonthDayYear
Date
Signature

Clear
Should be Empty: