Authorization for Autopsy
I, _____________________________, being entitled by law to control the disposition of the remains of ______________________________hereby authorize Pathology Services, P.C., its pathologists, agents, and representatives to conduct a:
_____ complete _____ chest/abdomen _____ head only
post-mortem examination (autopsy) upon the body of the deceased, including the removal and retention of such organs and parts of such organs and tissues as may be deemed proper by the examining physician in the interests of determining the cause(s) of death and of advancing medical knowledge and progress.
I understand that Medicare and health insurance companies do not routinely pay for any costs associated with any autopsy. I further understand that the cost of this particular autopsy will be paid by:
Witnesses (2) to the person signing for authorization of the autopsy:
Signature of Witnesses
Signature of Person Authorizing Autopsy
Relationship to deceased
Date Signed Address of Person Authorizing Autopsy
Two copies of the autopsy are routinely provided to the hospital for inclusion in the deceased's medical record for the attending physician. It is the attending physician who usually reviews the autopsy findings with the family. If an additional copy is requested for the family, please provide the appropriate name and address for the recipient.