AUTOPSY AUTHORIZATION

Name of Patient:                                                                                                        

Date/time of death:                                                                                                

In the hope that this authorization will further medical knowledge and progress, I, 

                                                                                                , being the legal next

 of kin to the above named individual, hereby authorize a postmortem examination.

 Such examination will be  full  /   subject to the following restrictions:

 I understand that tissue and/or other specimens may be retained as deemed appropriate by the

 examining physician for diagnostic or other scientific purpose.  

SIGNED:                                                                  WITNESSES

DATE:                                                                                                                                          

TIME: