Fillable ORDER FOR RELEASE (County of Los Angeles / Internal Services Department)

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ORDER FOR RELEASE (County of Los Angeles / Internal Services Department)

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COUNTY OF LOS ANGELES ORDER FOR RELEASE – ORDEN DE ENTREGA DEPARTMENT OF MEDICAL EXAMINER-CORONER
5
Please read and answer all questions before signing
Was the decedent legally married at the time of death? Yes
Yes
Yes
Yes
No
No
No
No
Does the decedent have any living adult children?
Does the decedent have any living minor children?
Does the decedent have any living parents?
Favor de leer y contestar todas las preguntas antes de firmar
SI NO
SI NO
SI NO
¿El difunto ha sido casado legalmente?
¿El difunto tiene hijos adultos ?
¿El difunto tiene hijos menores de edad vivientes?
¿El difunto tiene padres vivientes? SI NO
Case No.
Case Name
HEALTH AND SAFETY CODE § 7100 CUSTODY AND DUTY OF INTERMENT
"WARNING: The person signing this Order for Release is liable for all damages caused by any untruthful statements contained in this
document. (Health and Safety Code Section 7110). It is also a criminal offense to knowingly file a false statement with a government agency.
(Penal Code Section 115 and 470)"
The right to control the disposition of the remains of a deceased person unless other directions have been given by the decedent pursuant to Section 7100.1, vests in, and the
duty of disposition and the liability for the reasonable cost of disposition of the remains devolves upon, the following in the order named: (1) An agent under a power of
attorney for health care who has the right and duty of disposition under Division 4.7 (commencing with Section 4600) of the Probate Code; (2) The competent surviving spouse;
(3) The sole surviving competent adult child of the decedent or, if there is more than one competent adult child of the decedent, the majority of the surviving competent adult
children. (4) The surviving competent parent or parents of the decedent. If one of the surviving competent parents is absent, the remaining competent parent shall be vested
with the rights and duties of this section after reasonable efforts have been unsuccessful in locating the absent surviving competent parent.(5) The sole surviving competent
adult sibling of the decedent or, if there is more than one surviving competent adult sibling of the decedent, the majority of the surviving competent adult siblings. (6) The
surviving competent adult person or persons respectively in the next degrees of kinship; (7) A conservator of the person or estate appointed under Part 3 (commencing with
Section 1800) of Division 4 of the Probate Code when the decedent has sufficient assets. (8) The public administrator when the deceased has sufficient assets.
Therefore, please release the body upon completion of your death investigation of said deceased to:
_________________________________________________________________________________________________
NAME OF MORTUARY
_____________________________________________________________ ______________________________ _______________________________
NAME OF NEXT-OF-KIN (PLEASE PRINT LEGIBLY) RELATIONSHIP NEXT-OF-KIN’S SIGNATURE
_____________________________________________________________ ______________________________ ______________________________
ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER DATE SIGNED
_________________________________________ __________________ __________________________________________ ___________________
NAME RELATIONSHIP ADDRESS / CITY / STATE / ZIP CODE TELEPHONE NUMBER
CÓDIGO SALUD Y SEGURIDAD • § 7100 • CUSTODIA Y OBLIGACIÓN DE ENTERRO
"AVISO: La persona que firma esta documento será responsable de su contenido y responderá por cualquier daño(s) producto de cualquier
información falsa contenida en el mismo. (Sección 7110 Del Código De Salud y Seguridad) Además, es una ofensa criminal proveer información
falsa a propósito a una entidad del gobierno. Código Penal Sección 115 y 470"
El derecho a controlar la disposición de los restos de una persona fallecida, el deber de la disposición y la responsabilidad por el costo razonable de la disposición
corresponde a los siguientes en el orden indicado abajo, a menos que otras direcciones hayan sido dadas por el difunto de acuerdo con la Sección 7100. 1, y (1) Un agente con
un poder notarial para decisiones de la salud, el cual tiene el derecho y el deber de la disposición conforme a la División 4.7 (comenzando con la Sección 4600) del Código de
Sucesiones; (2) El cónyuge sobreviviente competente; (3) El único hijo sobreviviente adulto competente del difunto o, si hay más de un hijo adulto competente, el consenso de
la mayoría de los hijos adultos sobrevivientes competentes. (4) El padre sobreviviente competente o a los padres del difunto. Si uno de los padres competentes supervivientes
está ausente, el padre competente presente se le concederá a los derechos y deberes de esta sección siempre y cuando esfuerzos razonables para localizar al padre ausente
no han tenido éxito. (5) El único hermano adulto sobreviviente competente del difunto o, si hay más de un hermano adulto sobreviviente competente del difunto, el consenso
de la mayoría de los hermanos adultos sobrevivientes competentes. (6) El sobreviviente adulto competente o personas, en los grados de parentesco próximo. (7) Si el difunto
tiene activos suficientes, un tutor del individuo o de la propiedad, designado de acuerdo a la parte 3(comenzando con la Sección 1800) del 4º Capítulo del Código de
Sucesiones. (8) El administrador público cuando el fallecido tiene activos suficientes.
Por lo tanto, tras la finalizar la investigación de la muerte del susodicho individuo, favor de entregar sus restos a:
_________________________________________________________________________________________________
NOMBRE DE FUNERALIA
_____________________________________________________________ ____________________________ ________________________________
NOMBRE DE PARENTESCO (ESCRIBA EN LETRA DE MOLDE PARENTESCO FIRMA DE PARENTESCO
_____________________________________________________________ _____________________________ ________________________________
DIRRECION CUIDAD ESTADO ZONA POSTAL NUMERO DE TELEFONO FECHA DE FIRMA
SI USTED NO ES EL PARIENTE PRÓXIMO DE ACUERDO A LA LEY, FIRME Y EXPLIQUE PORQUE EL PARIENTE PRÓXIMO NO ESTÁ HACIENDO LOS TRÁMITES EN ESTE
ASUNTO. SI ES EL ALBACEA DEL TESTAMENTO, FAVOR DE INCLUIR UNA COPIA DEL MISMO JUNTO A ESTE DOCUMENTO.
_________________________________________ ____________________ __________________________________________________ ____________________
PARIENTE PRÓXIMO PARENTESCO DIRRECION / CUIDAD / ESTADO / ZONA POSTAL NUMERO DE TELEFONO
760739 – (REV. 4/2015)
ADDITIONAL DECEDENT INFORMATION ON REVERSE
IF THE LEGAL NEXT-OF-KIN IS NOT HANDLING, PLEASE ENTER NEXT-OF-KIN INFORMATION BELOW AND EXPLAIN WHY THEY ARE NOT HANDLING. ATTACH SUPPORTING AUTHORIZATION
DOCUMENTS, E.G. WILLS, POWER OF ATTORNEY, FAXES, ETC.
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signature
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County of Los Angeles
INFORMATION OBTAINED BY MORTUARY FROM FAMILY
Department of Medical ExaminerCoroner
Attending Physician:________________________________________ Phone:_______________________________________
Address: __________________________________________________ Date Last Attended:____________________________
Diagnosis:_________________________________________________________________________________________________
___________________________________________________________________________________________________________
Surgery: ______________________________ Date: ___________ Hospital:_________________________________________
WITNESSED DEATH: Yes No If no, LAST KNOWN ALIVE Date:____________________ Time:__________________
Date and Time Discovered: __________________________________ Where:___________________________________
By Whom: _____________________________________________________ Police Agency Investigated: Yes No
If Yes – Name and Division of Police Agency:_________________________________________________________________
REST HOME OR CONVALESCENT HOSPITAL DEATH:Date Admitted:___________________________________________
Admitting Diagnosis: ______________________________________________________________________________________
__________________________________________________________________________________________________________
TERMINAL EVENT OR HOW DISCOVERED/ KNOWN MEDICAL HISTORY, RECENT COMPLAINTS OF ILLNESSES AND ANY PERTINENT
INFORMATION:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
HISTORY OR EVIDENCE OF INJURY: Yes No TYPE OF INJURY: ________________________________________________
Date and Time of Injury: ___________________________ Address: ______________________________________________
City:_________________________________________________ State: ______________________________________________
At Work: Yes No At Home: Yes No If Neither, where:_______________________________________________
How Did Injury occur: _____________________________________________________________________________________
___________________________________________________________________________________________________________
ALL MEDICAL EVIDENCE LIST BELOW
Date Amount Amount
℞ No ______________ Filled:_____________ Contents: ______________ Prescribed:________Remaining:________
___________ ________ ________
________
________
________
________
______________
______________
______________
______________
___________
___________
___________
__________________
__________________
__________________
__________________
________ ________
THIS FORM COMPLETED BY: ___________________________________________________________________________________
DECEDENT PERSONALLY IDENTIFIED BY: / IDENTIFICATION HECHA POR:
Witness / Testigo: ________________________________ Signed / Firma:___________________________
Print / Molde:_____________________________ Print/ Molde :____________________________________
(ESCRIBA EN LETRA DE MOLDE)
Address / Domicilio:______________________
City / Ciudad:____________________________
Telephone No. / Telefono:________________
Address/ Domicilio:______________________________
City/ Cuidad: _______________________________________
Date Signed / Fecha De Firma: _________________________
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ORDER FOR RELEASE (County of Los Angeles Internal Services Department)

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Completed 13 August 2020

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