LOGAN HOSPITAL AUTHORITY TO RELEASE DECEASED BODY

AUTHORITY TO RELEASE DECEASED BODY
The Director of Medical Services of Hospital
Being the personal representative / senior available next of kin and the person responsible for making funeral arrangements for the late:
Deceased’s Full Legal Name:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender:
Last Residential Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Authorise to take possession of the body of the deceased,(Funeral Home Name)for the purpose of conducting funeral arrangements.
Funeral Home Name
Signature
Print Name:
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
In the event the personal representative/senior available next of kin is not available to sign (e.g. Interstate),then a Justice of the Peace who has received verbal instructions from that person(s) to remove the deceasedmay sign in their absence to confirm the authority granted to remove the deceased’s body
Signature
Print Name:
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty: