Authorization For Postmortem Examination [Fetal Death]

I, the undersigned, request and authorize a complete postmortem examination of the remains of ________________________, including removal, retention, or use of any part of the body and any derived information for scientific, diagnostic, therapeutic or other medical purposes deemed proper by the physicians. This permission includes (cross out any specifically excluded):

photographs
radiologic examination
removal, examination and retention of internal organs
removal and examination of brain and spinal cord

other ________________________

I further authorize that all information derived from this postmortem examination and prenatal and perinatal records be released to ________________________.

I wish the remains to be released to ________________________. [funeral home]

I state that I am the ________________________of the deceased and entitled by law to control the disposition of the remains and therefore authorized to request the above procedures in accordance with chapter 155, Wisconsin Statutes.

________________________[witness]

________________________[witness]