Notification of Hospice Death

2_revised

Baldwin County Coroner
Office: (251) 970-4051
Fax: (251) 947-0263
Email: coroner@baldwincountyal.gov

For Office Use Only
Case Number: __________________
Date/Time Received: _____________

*NOTIFICATION OF THE DEATH OF (full name)

*Date of Birth

*Age

Race

*Sex

*SSN

*Address

*City

*State

*Zip

Next of Kin

*Primary Contact Phone #

Relationship

Second Contact Phone #

Address

City

State

Zip

*Date of Death

*Time of Death

*Place of Death

Pursuant to Code of Alabama 45-37-60 and 22-9A-14, the coroner’s office should immediately be notified if there is suspicion of criminal violence or criminal neglect, when death occurs in suspicious or unusual circumstances, when deaths are thought to result from trauma or violence, in any prison or penal institution, or when in police custody; whether the cause is known or suspected, primary or contributory, or recent, delayed, or remote.

Please Initial:

To the best of my knowledge there have been no injuries, poisonings, or other suspicious circumstances since pre-registration and time of death.

To the best of my knowledge all medications are intact and there is no evidence of poisoning or overdose.

I certify that I have disposed of medications properly.

To the best of my knowledge the death is of natural causes from the terminal diagnosis given.

Circumstances Surrounding Death:

Cause of Death:

Doctor Certifying the Death:

Medical Facility/Practice Name:

Funeral Home

Phone

Address

Reporting Agency:

Phone

Date of Report

Email

Name of Hospice Representative:

Signature

Date

Time