Form Cme 19P PDF Details

Form CME 19P is a document used in the healthcare industry to ensure that all billing and coding procedures are accurately followed. This form can be used by both providers and insurance companies to ensure that all charges are legitimate and that no mistakes are made during the billing process. By using Form CME 19P, both parties can avoid any potential problems or disputes that may arise later on.

QuestionAnswer
Form NameForm Cme 19P
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesCremation_Permi t_Application online request for an autopsy report wv form

Form Preview Example

OFFICE OF THE CHIEF MEDICAL EXAMINER

CREMATION PERMIT APPLICATION (CME-19P)

STATE OF OKLAHOMA--BOARD OF MEDICOLEGAL INVESTIGATIONS

APPLICATION

FULL NAME OF DECEDENT --

First

Middle

Last

AGE

DATE OF BIRTH

RACE

SEX

 

RESIDENCE ADDRESS --

Street and Number

 

 

 

 

 

 

 

 

City or Town

 

County

 

 

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LOCATION OF DEATH --

Hospital or Other Institution

 

 

 

 

 

 

City or Town

 

County

 

DATE OF DEATH

 

TIME OF DEATH

 

(If not in either, give address)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPLICANT -- (Typed of Printed Name)

 

ADDRESS OF APPLICANT

 

 

 

 

RELATIONSHIP TO DECEASED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FUNERAL DIRECTOR IN CHARGE OF ARRANGEMENTS

 

 

 

 

 

 

NAME AND LOCATION OF CREMATORY OR OTHER FACILITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DISPOSITION OF REMAINS -- Cremation, burial at sea, storage, ot other (specify)

 

 

 

 

 

 

 

 

 

 

 

I hereby certify that I am the person having the legal authority to dispose of the remains of the above-named decedent and that the application is made herewith for permission to dispose of the body.

WITNESS (Signature)

APPLICANT (Signature)

PERMIT BY MEDICAL EXAMINER

RECEIPT NUMBER

* PERMIT NUMBER:

(Not valid without number assigned by Office of the Chief Medical Examiner)

I hereby certify that I have investigated the death of the above-named individual in accordance with the provisions of Title 63 OS 1971, Sections

931-955, as amended. In my opinion, the cause of death is:

and the manner of death is:

Natural

Pending

 

Suicide

Accident

 

Homicide

Unknown

In accordance with Title 63 OS 1971, Section 1-329, as amended, permission for disposal is hereby granted.

*THIS PERMIT IS NOT REQUIRED FOR TRANSPORT OUT OF STATE

DATE

COUNTY OF APPOINTMENT

MEDICAL EXAMINER (Signature)

VALID ONLY WITH ASSIGNED PERMIT NUMBER AND WITH SIGNATURE OF MEDICAL EXAMINER

FUNERAL DIRECTOR INSTRUCTIONS

1.Complete upper portion of application including necessary signatures.

2.FAX cremation application and information sheet to the appropriate medical examiners office. I.E. Oklahoma City or Tulsa. If FAX is not available, contact appointed office for instructions.

3.The medical examiners office will complete the application, including the permit number and doctors signature.

4.The medical examiners office will FAX the funeral home the completed cremation application.

5.The funeral home may proceed with cremation and present the completed facsimile cremation form to crematory.

6.The medical examiners office will mail the funeral home the original death certificate and a copy of the cremation permit to be filed with the local registrar.

7.The funeral home is required to submit the $100.00 fee to the appropriate medical examiners office within 48 hours.PLEASE INDICATE DECEDENTS NAME AND

PERMIT NUMBER WITH PAYMENT.

NOTE: ALL CREMATIONS ARE INVESTIGATED BY THE MEDICAL EXAMINERS OFFICE 1.E. OKLAHOMA CITY OR TULSA. DO NOT CONTACT LOCAL MEDICAL EXAMINERS

This form may be reproduced by the funeral home.

CME -- 19P (7-93)

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