CONSENT FOR AUTOPSY

Date ___________________

Time ___________________

I ____________________________ bearing the relationship of __________ and being the next of kin to ________________________ recently deceased, hereby authorize the representative of Clinch Valley Medical Center to make an examination of the body of the deceased and of its tissues as may be necessary.

I understand that the report and certain tissues as necessary may be released to the United States Public Health Service if requested by the service.

In addition, all patient records at this facility including results of tests performed at reference laboratories will be available for review by the hospital pathologist performing the autopsy. Note - this does not apply to autopsies performed by the medical examiner.

Extent of Autopsy:  Lungs Only (unless otherwise specified)     ______________________

          __________________________

                                                                                                             Signature next of kin

Witness:  ______________________________

Occupational and Medical History

Date of birth of Deceased:      ____________________________

Social Security Number:          ____________________________

Date and Place of Death:         ____________________________________________

                                                                Month,     Day,     Year,     City,     County,     State

Place of Last Mining Employment:

                                Name of Mine                          _______________________________________

                                Name of Mining Company        _______________________________________

                                Mine Address                          _______________________________________

Last Job Title at Mine of Last Employment ___________________

Job Title of Main Occupation (that job to which miner devoted the most number of years) __________ and surface or underground ________________.

Smoking History:

                                Did he ever smoke?                ______ yes     ______ no

                                If yes, for how many years? ______

                                If yes, how many cigarettes on average per day? _____

Total years in Surface Employment in Coal Mining, by state (if known).                _____ Years           _____ State

Total years in Underground Coal Mining Employment, by state (if known)             _____ Years           _____ State

After the examination the body of the deceased will be transferred to ________________ funeral home.

Body of _____________________________ is hereby received at (time) _______ on (date) __________.

                                                                                _______________________________

Funeral Director or representative