36C25818R0052-015.pdf

548 KB Posted

Attached to
Decedent Services
Solicitation number
36C25818R0052
Issued by

About this file

From the source

36C25818R0052 6.1.5.SF523A.Disposition of Body.pdf

View the file

Other files

File Type Posted
36C25818R0052-00002000.docx DOCX document
36C25818R0052-00001000.docx DOCX document
36C25818R0052-012.pdf PDF
36C25818R0052-009.docx DOCX document
36C25818R0052-016.pdf PDF
36C25818R0052-010.docx DOCX document
36C25818R0052-013.pdf PDF
36C25818R0052-014.pdf PDF
36C25818R0052-011.pdf PDF
36C25818R0052-008.docx DOCX document

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

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 at on A.M.

P.M.

was received (Name)

(Date) at A.M.

P.M. on .

(Date)

(Signature)

YES NO

REGISTER NO.

DISPOSITION OF BODY

Medical Record

WARD NO.

STANDARD FORM 523-A (REV. 12-53)

Prescribed by GSA/ICMR FRMR (41 CFR) 201.5-202.1)

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 at on A.M.

P.M.

was received (Name) (Date) at A.M.

P.M.

on (Date) (Signature)

YES

NO

REGISTER NO.

DISPOSITION OF BODY

Medical Record

WARD NO.

STANDARD FORM 523-A (REV. 12-53)

Prescribed by GSA/ICMR FRMR (41 CFR) 201.5-202.1) 8.2.1.3144.1.471865.466429

Name of deceased.:
Name of deceased.:
Body Removed by (Name and address of undertaker):
Body Received at (Time):
Body Removed at (Time):
REGISTER NUMBER.:
WARD NUMBER.:
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).:
Body Received on (Date). Enter 2 digit month, 2 digit day and 4 digit year.:
Body Removed on (Date). Enter 2 digit month, 2 digit day and 4 digit year.:
Signature of person releasing body to undertaker. Digital Signature.:
Signature of representative of undertaker. This is a protected field.:
Signature of Physician. This is a protected field.:
Signature of person releasing body to undertaker. This is a protected field.:
Signature. This is a protected field.:
THIS BODY CONTAINS A MEDICAL IMPLANT WHICH MAY INCLUDE A BATTERY OR POWER CELL. YES.: 0
THIS BODY CONTAINS A MEDICAL IMPLANT WHICH MAY INCLUDE A BATTERY OR POWER CELL. NO.: 0
CheckBox1: 0
CheckBox2: 0
CheckBox1a: 0
CheckBox2b: 0

File details come from the government source that posted it.