CONFIDENTIAL
Authorization & Contract for Postmortem Services
CASE NO.
| CASE NO. |
|
Decedent’s Name |
|
| Date of Birth |
|
Approx. Weight |
|
| Date of Death |
|
Approx. Height |
ft inch |
| Ethnicity |
|
| Next-of-Kin |
|
Funeral Home |
|
| Email |
|
Phone (Funeral Home) |
|
| Phone |
|
Home Address |
|
1). I certify that I am the (relationship) of the deceased
Funeral Home Return Address:
Services & Fees
| # |
Service |
Details / Amount |
| 1 |
Autopsy Procedure: |
|
| 2 |
Tissue/DNA/Appliance Procurement: |
|
| 3 |
Transportation/Shipping |
|
| 4 |
Toxicology Analysis |
|
| 5 |
Neurological Diagnosis (Brain-Only Autopsy) |
|
| 6 |
Mesothelioma Diagnosis (Lung-Only Autopsy) |
|
| 7 |
X-Ray |
|
| TOTAL |
|
Financial Agreement
1). The undersigned recognized that the Pathologist furnishing services to the decedent/family is an independent contractor and is not an employee or agent of 1-800-AUTOPSY/Autopsy Post Services, Inc. Please be advised that the total cost for postmortem procedure must be paid to the order of (Pathologist).
2). The undersigned agrees, in consideration of services rendered, that he/she individually obligate himself/herself to pay the amount in accordance with the rates and terms. Should the account be referred to an attorney or collection, the undersigned shall pay reasonable attorney’s fees, court fees and collection expenses. All delinquent account bear interest at the legal rate. Autopsy results will not be available until check is cleared by financial institution.
3). Photographs are not automatically returned to families with completed report unless specifically requested due the graphic nature and subject matter. We will forward photographs to a designated person upon written request.
4). If Toxicology analysis is necessary there will be an additional charge.
5). This contract provides for postmortem services only. It does not retain the Pathologist as an expert witness.
6). Make Cashier’s Checks payable to for fee listed above.
Payment Information
Billing Address
Electronic Signature
