I hereby attest that the information entered
on the OCME report/record request form accurately reflects my relationship with
the decedent and my name and contact information. I affirm that this
information is true, accurate, and complete to the best of my knowledge. I
agree that the use of such typed electronic signature constitutes the legal
equivalent of my manual signature, and I understand that any falsification,
omission, or concealment of material fact my subject me to administrative, civil,
or criminal liability.