Next of Kin (NoK) authorization for release of records

Release records (name)
Authorization from

Release records (name)
Authorization from

M. E. Case number

Release to (name)

Organization

Address

Address line 2

City

State

Zip Code

City, State, Zip Code

Relationship to deceased

I hereby authorize Hennepin County Medical Examiner's Office to obtain copies of records and/or discuss events, history and medical findings concerning

Name of deceased

Date of death

Name of person authorizing Release of Information

Relationship to deceased

Address

Address line 2

City

State

Zip Code

City, State, Zip Code

Phone number

Check if you would like a copy sent to you by email

Email

Please confirm your email address

Signature

Some specific browsers or devices may not work properly with the signature field. If you have issues, please try another device.

Date

**The NoK Authorization is valid for 1 year from the date of submission.

I have reviewed all of the information and I believe it to be correct.