Larry Hogan, Governor · Boyd K. Rutherford, Lt. Governor

STATE ANATOMY BOARD


12/27/2024

CREMATION AUTHORITY

First Middle Last Name Date of Death Body # Month/Year E-Number

Juan Ortega, Director


Date

Crematory Representative (Sign)


The State Anatomy Board agrees to hold the crematory and the mortician transporting the body harmless, and to indemnify each of them against liability, costs or damages arising out of this authorization to cremate and/or deliver the cremated remains.

NOTE: The cremated remains are to be placed in an urn and returned to the State Anatomy Board.

655 W. Baltimore Street, BRB Bldg. ∙ Room B-026 ∙ Baltimore, MD 21201
Phone: 410-547- 1222 ∙ Fax: 41-706-8107
In State toll Free 1-800-879-2728 ∙ TT 1-800-735-2258
Web Site: health.maryland.gov/anatomy