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Notification of Hospice Death

2. 

3. <table> <tr> <td> Shelby County Coroner<br/> 108 West College St<br/> Butch Ellis Bldg Room 107<br/> Columbiana, Alabama 35051<br/> Office: (205) 669-3846<br/> Fax: (205) 669-3886<br/> Email: coroner@shelbyal.com<br/> </td> <td style="padding-left:25px;vertical-align:top"> (Mailing Address)<br/> PO Box 1321<br/> Columbiana, Alabama 35051<br> </td> <td style="vertical-align:top;padding-left:15px"><div style="padding:5px;border:1px solid #000000;min-width:225px"> <div style="font-style:italic;color:rgb(16, 96, 116)">For office use only.</div> Case #:<br> Date/Time received:<br> Employee's name: EVANS </div> </td> </tr> </table>

   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 <span style="font-style:italic">Code of Alabama 45-37-60 and 22-9A-14</span>, 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.

    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*

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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