Decedent identification

Referring agency
Decedent

Referring agency
Decedent

Referring agency
Decedent

Referring location

C / ME Referral

Courtesy Hold

County

State

Investigator name (first and last)

Agency

Phone

Agency representative name (first and last)

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To the best of my knowledge, the remains brought to the Hennepin County Medical Examiner's Office are those of:

Last name

First name

Middle

Date of birth

Address

City

State

Zip Code

To the best of my knowledge, the remains brought to the Hennepin County Medical Examiner's Office are those of the above named individual. I submit that this form is sufficient for decedent identification purposes unless the Hennepin County Medical Examiner determines that confirmatory identification procedures are warranted.

Signature

Date

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