R.H.C. Release

Date:December 6, 1995
Pages:1

HCA NEW PORT RICHEY HOSPITAL<

MCPHERSON LISA

[illegible patient info]

Date 12-5-95

R.H.C. RELEASE

I, the (Husband, Wife, Daughter, Son, Sister. Brother or Legal Representative), authorize HCA New Port Richey Hospital, of Florida, to release the body of

[handwritten: ] Lisa McPherson<

(Name of Deceased)

to _____________________ (Funeral Home)

I certify that no member of HCA New Port Richey Hospital staff has endeavored to influence my decision in the selection of the above named funeral home.

Witness: __________________________

Signature: ________________________

Address: _________________________

Time and Date

Body Received 0400 A.M P.M. 12-6 1995

By

W. Sample for M.E.O. Dist 6

Funeral Director or Representative

FORM CH047