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 HILLSBOROUGH COUNTY MEDICAL EXAMINER DEPARTMENT 11025 46th Street North Tampa, FL 33617 PHONE 8139144567 FAX 8139144596 PERMIT F 2009-2023

HILLSBOROUGH COUNTY MEDICAL EXAMINER DEPARTMENT 11025 46th Street North Tampa, FL 33617 PHONE 8139144567 FAX 8139144596 PERMIT F 2009-2023

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Financial Responsibility Date Printed Name of Legally Authorized Person Relationship to Deceased ADDRESS Witness Signature Print Witness Name Date Witnessed By claiming the Deceased s body or remains from the Medical Examiner s facility the abovenamed funeral director or direct disposer hereby certifies that the Deceased s body or remains are not unclaimed and agrees that in the event the above-named legally authorized person fails to assume financial responsibility for the disposition of the...
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