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Baldwin County Coroner

Office: (251) 970-4051

Fax: (251) 947-0263

Email: coroner@baldwincountyal.gov

Notification of Hospice Death

NOTIFICATION OF DEATH OF (full name):

Date of Birth:

Age:

Race:

Sex:

* SSN:

Street Address:

City:

State:

Zip Code:

Next of Kin Full Name:

Relationship:

Primary Phone Number:

Secondary Phone Number:

Street Address:

City:

State:

Zip Code:

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 the 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:

Funeral Home Phone:

Street Address:

City:

State:

Zip Code:

Reporting Agency:

Reporting Agency Phone:

Date of Report:

Name of Hospice Representative:

Hospice Representative Email:

Signature:

Date Signed:

Time Signed:

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