Public Information Request Form

Ada County Coroner

I hereby request information from the Ada County Coroner's Office regarding the following individual:
Name of Decedent*
Date of Birth
MM slash DD slash YYYY
Date of Death
MM slash DD slash YYYY
This information is requested by the following individual/provider:
Name*
Relationship to Decedent*
Address*
Street Address City State ZIP Code
Email*
Phone
Fax
Information requested*
Purpose: The above information is being requested from the Coroner's Office by the individual or provider listed above.

Voluntary Authorization: I understand that I may refuse to sign this authorization.

Expiration: I understand that I can revoke this request in writing, but if I do not revoke the request, it will automatically expire two years from the date this form is signed.

Revocation: I understand I can revoke my request at any time in writing, although any use or disclosure that occurred prior to the date of my revocation is not affected, and is only revocable to the extent that the Coroner’s Office has not acted in reliance on it.

Copy: I understand that I can receive a copy of this completed form.
By typing out my signature below I am confirming my request for information. I also swear or affirm that I am the individual requesting the information listed above.
Signature*

Please type out your signature
Date*
MM slash DD slash YYYY
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Idaho Code § 74-113, 115 & 120 permits Ada County to verify requestor’s identity for the purpose of: Protecting personal information in compliance with state and federal law, and to ensure this information is NOT for purposes such as mailing/solicitation list or to supplant a discovery procedure.