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Office of the Chief Medical Examiner
Application for Cremation, Anatomical Donation or Burial at Sea Approval (
*
= Mandatory field
)
Request Type:
Cremation Approval $75.00
Anatomical Donation $0.00
Burial at Sea $75.00
Decedent Info:
Decedent First Name:
Decedent Last Name:
Decedent SSN:
Decedent Sex:
M
F
Date/Time of Death:
Date of Birth:
Place of Death (facility name, or if not institution, give street address, city and zip code):
OCME Case Number (
if applicable
):
Requesting Institution Type:
hospital
funeral home
Requesting Institution Name:
Contact Info:
Contact First Name:
Contact Last Name:
Contact Phone:
Contact Email:
Comments:
Payment Information:
Credit Card Type:
Visa
MasterCard
Discover
American Express
Credit Card Number:
Credit Card Expiration Date:
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2025
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Cardholder Name:
Cardholder Address:
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