I (We) request and authorize a complete autopsy on the body of: ___________________________________________________________________________________and I (We) authorize the removal and retention or use for diagnostic, scientific or therapeutic purposes such organs, tissues and parts as may be indicated or desirable. 

This authority is granted subject to the following restrictions: ______________________________________________     (if no restrictions, write none)
 The following special examinations shall be made: __________________________________________________________________________________ 
I (We) represent that I am (We are) the _________________________________________________  (Relationship) to the deceased and entitled by law to control disposition of the body. 

____________________________________ 		_____________________________________
Signature of Authorizing Person					Relationship to the deceased
____________________________________		___________________	_______________
Printed Name							Phone # 				Date
____________________________________		___________________
Witness Signature							Date

Funeral Home or Mortuary:______________________________________________________
Address:_______________________________________________________________
City, State, Zip :_________________________________________________________
	Phone #:______________________________

NOTE: To be completed in triplicate. 
White: Patient's Chart 	Canary: Unit Manager 	Pink: Accompany Body to Funeral Home or Mortuary