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Notification of Hospice Death
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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
Date
*
Date
NOTIFICATION OF THE DEATH OF (full name)
*
Age
*
Race
*
Sex
*
M
F
Date of Birth
*
Date of Birth
SSN
*
Date of Death
*
Date of Death
Time of Death
*
Time of Death
Place of Death (facility name/address)
*
Address
*
City
*
State
*
Zip
*
Next of Kin
Relationship
Address
City
State
Zip
Phone
Phone
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.
Doctor Certifying the Death
*
Phone
*
Circumstances Surronding Death
(e.g. disease, injury/trauma, motor vehicle collision, suspected overdose, etc.)
Manner of Death
*
(Natural, Accident, Homicide, Suicide, Unknown)
Cause of Death
*
Mortuary
*
Phone
Hospice Company (name)
*
Phone
*
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