Check all that apply:
Race:
Legal Next of Kin / Authorized Health Care Agent

(Refer to MN Statute 149A.80 subdivision 2, if unsure who is next of kin)

    Power of Attorney / Decision-Maker for the next of kin

        I have verified with the certifying physician that the death record will be completed as follows:

        [Must be Licensed Agency]

        *This form will be retained in the coroner’s / medical examiner’s office and the registration will be in effect for 180 days from the date last seen by the physician. At that time, a new form must be submitted by the registering agency.