Medical Examiner / Coroner Update Form
Today’s date:
Type of update:
Add
Delete
Change
Choose Title:
Coroner
Deputy Coroner
Medical Examiner
Assistant Medical Examiner
Other (Specify) _______________________________________________________________
First Name
Middle Initial
Email Address
Last Name
License Number
County/Counties of Jurisdiction
NPI Number
Clinic/Office Name
Phone Number
Clinic/Office Address
Signature of authorizing coroner or medical examiner is required to add/delete deputies or assistant medical
examiners. When changing information, a deputy coroner or assistant medical examiner may sign.
Signature
Phone
Fax
Scan and email (preferred), or fax the completed form to:
Email: [email protected]
Fax:
651-201-5750
Contact the Office of Vital Records Help Desk line at 651-201-5970 with questions or for assistance.
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OFFICE OF VITAL RECORDS
May 2017