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Mortuary Admission Form

This mortuary admission form is used to document the intake and release of deceased patients. It collects information such as the patient's name, date of birth, date and cause of death. It documents the property with the body, identifying marks, and the names of those admitting and receiving the body. The form also requests consent to keep the body in the mortuary for a specified time and handles matters such as post-mortem examinations and contagious disease protocols.

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Hrishikesh Kalgaonkar
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4K views1 page

Mortuary Admission Form

This mortuary admission form is used to document the intake and release of deceased patients. It collects information such as the patient's name, date of birth, date and cause of death. It documents the property with the body, identifying marks, and the names of those admitting and receiving the body. The form also requests consent to keep the body in the mortuary for a specified time and handles matters such as post-mortem examinations and contagious disease protocols.

Uploaded by

Hrishikesh Kalgaonkar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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MORTUARY ADMISSION FORM

This form must be filled completely every time while accepting & releasing a dead body.
Name of Patient: Date of Birth:
Age: Sex: Male Female 
Fathers name (if applicable):
Mothers name (if applicable):
Date of Death: Date being admitted to mortuary:
Admitted from, (Ward or Hospital): Time being admitted to mortuary:
Mortuary attendant’s name receiving body:
Certificate of cause of death available Yes No Sign:
Property with body (including placenta/notes/clothing etc.):
1.
2.
3.
4.
Identification Marks: (Mention at least two) / Registration Tag No.
1.
2.
Name of persons admitting the body:
1...................................................................................................Sign................... ID Proof:

2..................................................................................................Sign................... ID Proof:

Consent to keep the dead body in Saideep Healthcare & Research Mortuary:
We ...............................................................................................................................................................................................

hereby request Saideep Healthcare & Research Hospital to keep the dead body of .................................................................

....................................................................................................................................................................................................

in the mortuary for ................. hours/days for personal/ legal reasons.

 We agree to take the possession of the dead body after the above mentioned time period, failure to which Saideep
Healthcare & Research Hospital shall intimate us about handing over/disposing of the dead body in a way they deem
fit. We shall not raise any complaint/ initiate any legal action in such scenario.

 If it is suggested by the treating doctor to perform Post mortem examination to ascertain the cause of death we shall
arrange for it. In case we don’t perform the post mortem examination, we shall not demand the Cause of death
certificate from Saideep Healthcare & Research Hospital or its doctors.

 In the deaths due to contagious diseases, we shall abide with the rules and guidelines set by government about the
disposal of the dead body.
Receipt of the dead body
We have received the complete body and identified it as dead body of .................................................................................
*(In case of organ/body donation separate form must be attached)

We have received the belongings as mentioned above.

Name of persons receiving the body:

1.................................................................................................sign:...................................ID Proof___________________

2.................................................................................................sign....................................ID Proof___________________

Name of the mortuary attendant handing over the body: _________________________________________________

Sign: __________________________________ Date: ______________________ Time: _________________________

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