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Notification of Hospice Death

2. 

3. Shelby County Coroner 108 West College St Butch Ellis Bldg Room 107 Columbiana, Alabama 35051 Office: (205) 669-3846 Fax: (205) 669-3886 Email: coroner@shelbyal.com

   (Mailing Address) PO Box 1321 Columbiana, Alabama 35051

   For office use only. Case #: Date/Time received: Employee's name: EVANS

5. Date*
   Date
7. NOTIFICATION OF THE DEATH OF (full name)*
8. Age*
10. Race*
11. Sex*

    1. M
    2. F
12. Date of Birth*
    Date of Birth
13. SSN*
17. Date of Death*
    Date of Death
18. Time of Death*
    Time of Death
19. Place of Death (facility name/address)*
21. Address*
22. City*
23. State*
24. Zip*
28. Next of Kin
29. Relationship
30. Address
32. City
33. State
34. Zip
36. Phone
37. Phone
41. 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.
43. Doctor Certifying the Death*
44. Phone*
46. Circumstances Surronding Death
    (e.g. disease, injury/trauma, motor vehicle collision, suspected overdose, etc.)
48. Manner of Death*
    (Natural, Accident, Homicide, Suicide, Unknown)
49. Cause of Death*
53. Mortuary*
54. Phone
58. Hospice Company (name)*
59. Phone*
Leave This Blank:


61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

63. Submit

* indicates a required field