County of San Bernardino
OFFICE OF THE CORONER
ORDER FOR RELEASE

To: Brian McCormick
      Coroner, County of San Bernardino                                                                          Date _____________________
                                                                     Order for the release of the body of:
Name ____________________________________________________ Case No. ___________________________

                 "Warning: The person signing this Order for Release is liable for all damages caused by any untruthful statements
                 contained in this document:      (Health and Safety Code Section 7110). It is also a criminal offense to knowingly file a
                 false statement with a government agency. (Penal code Section 115 and 470)"

                                                                                          NEXT OF KIN
I certify that, pursuant to Section 7100, Health and Safety Code, State of California, it is my legal right to select any funeral director or disposition service.  Therefore, upon completion of your investigation of the death of the deceased, please release the body of the above deceased to the custody of:

Mortuary ___________________________________________________________________________________
Signed _______________________________________ Relationship ____________________________________
Address ______________________________________ City ___________________________ State __________
Telephone ____________________________________

                                                                                     NON RELATIVE
Reason for handling if not next of kin ______________________________________________________________
___________________________________________________________________________________________

I,_________________________________________________________________________________ bearing no
relationship to the above-named deceased, having executed the above authorization, do hereby assume full
responsibilities for the cost of all funeral services in connection therewith of the above-named funeral director.

Witness ______________________________________ Signed ________________________________________
Address ______________________________________ Address _______________________________________
City _________________________________________ City __________________________________________
Telephone ____________________________________ Telephone _____________________________________

                                              FUNERAL DIRECTOR DISPOSITION SERVICE
Acting as a representative of the firm of ___________________________________________________________
                                                                                                                      
  Name
____________________________________________________________________________________________
                                        
Address                                                                                       Telephone No.
I state that I am entitled to custody of the remains of the above-named deceased.
____________________________________________________________________________________________

I have examined Toe Tag # _________________which bears the name of _________________________________

Received by _______________________________________ of ________________________________________
                                                 
Name

Signed __________________________________________________

Released by _____________________________________________

Date _________________________ Time _____________________

RELEASE HOURS: MONDAY-FRIDAY, 0800-1200 AND 1300-1500 HOURS
RELEASING OFFICER FAX # (909) 388-8025                   MAKE COPY FOR FUTURE USE