Post by Admin on Sept 30, 2021 11:49:46 GMT
***STANDARD CERTIFICATE OF DEATH***
Please include Autopsy files here:
LOCAL FILE NO.
1. DECEDENT’S LEGAL NAME
(Include AKA’s if any) (First, Middle, Last)
2. SEX
3. SECURITY NUMBER
4. AGE-Last Birthday
(Years) Months Days Hours Minutes
5. DATE OF BIRTH (Mo/Day/Yr)
6. BIRTHPLACE (City and State or Foreign Country)
7a. RESIDENCE-STATE
7b. COUNTY
7c. CITY OR TOWN
7d. STREET AND NUMBER
7e. APT. NO. 7f. ZIP CODE
7g. INSIDE CITY LIMITS? □ Yes □ No
8. EVER IN MUNICIPAL EMPLOYEE? □ Yes □ No
9. MARITAL STATUS AT TIME OF DEATH
□ Married □ Married, but separated □ Widowed
□ Divorced □ Never Married □ Unknown
10. SURVIVING SPOUSE’S NAME (If Married, give name prior to first marriage)
11. FATHER’S NAME (First, Middle, Last)
12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)
13a. INFORMANT’S NAME
13b. RELATIONSHIP TO DECEDENT
13c. MAILING ADDRESS
14. PLACE OF DEATH (Check only one: see instructions)
IF DEATH OCCURRED IN A HOSPITAL:
□ Inpatient □ Emergency Room/Outpatient □ Dead on Arrival
IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
□ Hospice facility □ Nursing home/Long term care facility □ Decedent’s home □ Other (Specify):
15. FACILITY NAME (If not institution, give street & number)
16. SEDA LOCATION
18. METHOD OF DISPOSITION: □ Burial □ Cremation
□ Donation □ Entombment □ Removal from State
□ Other (Specify):_____________________________
19. PLACE OF DISPOSITION (Name of cemetery, crematory, other place)
20. COMPLETE ADDRESS OF FUNERAL FACILITY
NAME OF DECEDENT
____________________________________________
For use by physician or institution
To Be Completed/ Verified By:
______________________________________________________
FUNERAL DIRECTOR:
21. SIGNATURE OF FUNERAL SERVICE LICENSEE
22. LICENSE NUMBER (Of Licensee)
ITEMS
23. DATE PRONOUNCED DEAD (Mo/Day/Yr) 25. TIME PRONOUNCED DEAD
24. SIGNATURE OF PERSON PRONOUNCING DEATH (Only when applicable)
25. LICENSE NUMBER
28. DATE SIGNED (Mo/Day/Yr)
27. ACTUAL OR PRESUMED DATE OF DEATH
(Mo/Day/Yr) (Spell Month)
28. ACTUAL OR PRESUMED TIME OF DEATH
29. WAS MEDICAL EXAMINER OR CORONER CONTACTED?
□ Yes □ No
Please include Autopsy files here:
LOCAL FILE NO.
1. DECEDENT’S LEGAL NAME
(Include AKA’s if any) (First, Middle, Last)
2. SEX
3. SECURITY NUMBER
4. AGE-Last Birthday
(Years) Months Days Hours Minutes
5. DATE OF BIRTH (Mo/Day/Yr)
6. BIRTHPLACE (City and State or Foreign Country)
7a. RESIDENCE-STATE
7b. COUNTY
7c. CITY OR TOWN
7d. STREET AND NUMBER
7e. APT. NO. 7f. ZIP CODE
7g. INSIDE CITY LIMITS? □ Yes □ No
8. EVER IN MUNICIPAL EMPLOYEE? □ Yes □ No
9. MARITAL STATUS AT TIME OF DEATH
□ Married □ Married, but separated □ Widowed
□ Divorced □ Never Married □ Unknown
10. SURVIVING SPOUSE’S NAME (If Married, give name prior to first marriage)
11. FATHER’S NAME (First, Middle, Last)
12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)
13a. INFORMANT’S NAME
13b. RELATIONSHIP TO DECEDENT
13c. MAILING ADDRESS
14. PLACE OF DEATH (Check only one: see instructions)
IF DEATH OCCURRED IN A HOSPITAL:
□ Inpatient □ Emergency Room/Outpatient □ Dead on Arrival
IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
□ Hospice facility □ Nursing home/Long term care facility □ Decedent’s home □ Other (Specify):
15. FACILITY NAME (If not institution, give street & number)
16. SEDA LOCATION
18. METHOD OF DISPOSITION: □ Burial □ Cremation
□ Donation □ Entombment □ Removal from State
□ Other (Specify):_____________________________
19. PLACE OF DISPOSITION (Name of cemetery, crematory, other place)
20. COMPLETE ADDRESS OF FUNERAL FACILITY
NAME OF DECEDENT
____________________________________________
For use by physician or institution
To Be Completed/ Verified By:
______________________________________________________
FUNERAL DIRECTOR:
21. SIGNATURE OF FUNERAL SERVICE LICENSEE
22. LICENSE NUMBER (Of Licensee)
ITEMS
23. DATE PRONOUNCED DEAD (Mo/Day/Yr) 25. TIME PRONOUNCED DEAD
24. SIGNATURE OF PERSON PRONOUNCING DEATH (Only when applicable)
25. LICENSE NUMBER
28. DATE SIGNED (Mo/Day/Yr)
27. ACTUAL OR PRESUMED DATE OF DEATH
(Mo/Day/Yr) (Spell Month)
28. ACTUAL OR PRESUMED TIME OF DEATH
29. WAS MEDICAL EXAMINER OR CORONER CONTACTED?
□ Yes □ No