Release Form - Killick Family Funerals | Funeral Directors In Kingaroy

Authority To Release Form

To: The Director of Medical Services Of (Hospital)

I AM THE

Personal Representative
Senior available Next Of Kin and the person responsible for making funeral arrangements

THE NAME the

NAME of person authorised to arrange the funeral.

DECEASED Full Legal Name

DECEASED Date of Birth

DECEASED Gender

DECEASED Last Residential Address

Authorise KILLICK FAMILY FUNERALS to take possession of the body of the deceased, for the purpose of conducting funeral arrangements.

Name of Person Signing

Date

Signature

Clear Signature

I acknowledge Queensland State Laws will accept this communication as containing my signature within the meaning of the Electronic Transactions (Qld) Act 2001.

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Registration

Authority To Release Form

Authorise KILLICK FAMILY FUNERALS to take possession of the body of the deceased, for the purpose of conducting funeral arrangements.