Fillable Printable Medical Record Disposition Of Body
Fillable Printable Medical Record Disposition Of Body
Medical Record Disposition Of Body
The body of
(Name)
(Name and address of undertaker)
(Signature of representative of undertaker)
(Signature of Physician)
was removed
by
(Signature of person releasing body to undertaker)
The following statement shall be completed only when specifically ordered.
THIS BODY CONTAINS A MEDICAL IMPLANT WHICH MAY INCLUDE A BATTERY OR POWER CELL
PHYSICIAN'S STATEMENT REGARDING CONDITION OF REMAINS AS RELEASED (Describe post-mortem, surface discolorations,
abrasions, lesions, whether remains were embalmed, etc.)
PATIENT'S IDENTIFICATION (For typed or written entries give: Name -
last, first, middle; grade; date; hospital or medical facility)
MEDICAL RECORD
DISPOSITION OF BODY
RECEIPT OF BODY AT MORGUE
CERTIFICATE OF REMOVAL
Authorized for Local Reproduction
The body of
aton
A.M.
P.M.
was received
(Name)
(Date)
at
A.M.
P.M.
on
.
(Date)
(Signature)
YESNO
REGISTER NO.
DISPOSITION OF BODY
Medical Record
WARD NO.
STANDARD FORM 523-A (REV. 12/93)
Prescribed by GSA/ICMR FRMR (41 CFR) 201.5-202.1)
