1. Name of decedent (First/Given)

2. Middle

3. Last (Family)

NAME OF MORTUARY:

NEXT OF KIN SIGNATURE:

PRINT FULL NAME OF NEXT OF KIN:                                                                                    RELATIONSHIP:

PRINT ADDRESS OF NEXT OF KIN BELOW:                                             TELEPHONE: (        )

Address:                                                                                      City:                                         State/Zip: ____________________________________________________________________________________________________________________________________

RESPONSIBLE PARTY (if not next of kin) SIGNATURE:

PRINT FULL NAME OF RESPONSIBLE PARTY:                                                                         RELATIONSHIP:

PRINT FULL ADDRESS OF RESPONSIBLE PARTY BELOW:                   TELEPHONE: (      )

Address:                                                                                    City:                                          State/Zip:

Reason for handling in not next of kin:

CORONER'S FEE The fee of $300.00 is assessed to recover the expense of the contracted private transportation service employed to transfer the deceased from the place of death to the Orange County Coroner's Office.  this fee was adopted by the Orange County Board of Supervisors on February 25, 2003 per Ordinance #3844 and authorized by government Code Section 27472 and 54985. Remittance is expected upon release of the deceased to the funeral home. A personal check from the family or from the funeral home in the form of cash advance is to be attached to form. [  ] NEXT OF KIN INITIALS ______________   [  ]     DATE FEE PAID-RECEIVED BY____________________ [  ] NO FEE RECEIVED-REASON FOR FEE EXEMPTION            [  ] HOMICIDE  [  ] ACTIVE MILITARY            [  ] AGE 14 AND UNDER [  ] STATE HOSPITAL            [  ] BROUGHT IN BY MORTUARY              [  ] OTHER (PLEASE EXPLAIN)__________________________________________________________

PROPERTY RELEASE I certify that pursuant to Section 7100, Health & Safety Code, State of California, it is my legal right to take custody of personal property of the above deceased. Therefore, upon completion of your investigation of the death to the said deceased, please release the personal property of the above deceased to the custody of:

SIGNED:                                                                                                     RELATIONSHIP:

Address:                                                                               City:                                                                State/Zip

                                                           FUNERAL DIRECTOR/DISPOSITION SERVICE

Acting as a representative of the firm of __________________________________________________________________________
I state that I am entitled to the custody of the remains of the above named deceased by the authority of:
[  ]     Telegraphic authorization by proper next of kin  (Copy attached)
[  ]     By direction of the Public Administrator (Name:__________________________________________)
[  ]     Pre-need arrangement  (Copy attached)
[  ]     Other reason__________________________________________________________________________