Certificate Of Death Worksheet Form PDF Details

A Certificate of Death Worksheet Form is a document that proves the death of an individual. This form is used by government agencies, hospitals, and other organizations to provide necessary information about the deceased. The form includes the name of the deceased, date of death, and other pertinent information. The purpose of this form is to record all vital information about the individual who has passed away. The certificate of death worksheet form can be downloaded from the internet or obtained from government offices or hospitals. It is important to fill out this form accurately and completely to ensure that all necessary information is included. The completed form should be filed with the appropriate agency or organization.

QuestionAnswer
Form NameCertificate Of Death Worksheet Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namessc death worksheet, worksheet llb bs, sc death worksheet blank, sc death certificate worksheet

Form Preview Example

 

 

 

 

 

 

 

 

SOUTH CAROLINA CERTIFICATE OF DEATH

 

 

 

 

 

 

 

 

 

 

FUNERAL HOME WORKSHEET

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. DECEDENT’S LEGAL NAME (Include AKAs, if any) (First, Middle, Last)

 

 

 

 

2. SEX

3. SOCIAL SECURITY NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4a. AGE-Last Birthday

 

4b. UNDER 1 YEAR

4c. UNDER 1 DAY

 

 

5. DATE OF BIRTH

6. BIRTHPLACE (City and State or Foreign Country)

 

 

(Years)

 

 

 

 

 

 

 

 

 

(MM/DD/YYYY)

 

 

 

 

 

 

 

Months

 

Days

Hours

 

Minutes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7a. RESIDENCE-STATE

 

 

 

7b. COUNTY

 

 

 

 

 

7c. CITY OR TOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7d. STREET AND NUMBER

 

 

 

 

 

 

7e. APT. NO.

7f. ZIP CODE

 

7g. INSIDE CITY LIMITS?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

8. EVER IN US

 

9. MARITAL STATUS AT TIME OF DEATH

10. SURVIVING SPOUSE’S NAME (Name prior to irst marriage)

 

 

ARMED FORCES?

 

Married

Married, but separated

Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

Divorced

 

Never Married

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. FATHER’S NAME (First, Middle, Last)

 

 

 

12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13a. INFORMANT’S LEGAL NAME

13b. RELATIONSHIP TO DECEDENT

13c. MAILING ADDRESS (Street and Number, City, State, Zip Code)

18. METHOD OF DISPOSITION

Burial

Cremation

Donation

Entombment

Removal from state

Other (Specify) ________________________________________

19. PLACE OF DISPOSITION (Name of cemetery, crematory, other place)

20. LOCATION-CITY, TOWN, AND STATE

51.DECEDENT’S EDUCATION - Check the box that best describes the highest degree or level of school completed at the time of death.

8th grade or less

9th-12th grade; no diploma

High school graduate or GED completed

Some college credit, but no degree

Associate degree (e.g., AA, AS)

Bachelor’s degree (e.g., BA, AB, BS)

Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA)

Doctorate (e.g., PhD, EdD) or Profes- sional degree (e.g., MD, DDS, DVM, LLB, JD)

52.DECEDENT OF HISPANIC ORIGIN? Check the box that best describes whether the decedent is Spanish/Hispanic/ Latino/Latina. Check the “No” box if decedent is not Spanish/ Hispanic/Latino/Latina.

No, not Spanish/Hispanic/Latino/Latina

Yes, Mexican, Mexican American, Chicano/Chicana

Yes, Puerto Rican

Yes, Cuban

Yes, other Spanish/Hispanic/Latino/Latina

(Specify) _________________________________

53.DECEDENT’S RACE- Check one or more races to indicate what the decedent considered himself or herself to be.

White

Black or African American

American Indian or Alaska Native

(Name of the enrolled or principal tribe ) _________________

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian (Specify) ________________________________

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Paciic Islander (Specify)_________________________

Other (Specify)______________________________________

54.DECEDENT’S USUAL OCCUPATION (Indicate type of work done during most of working life. DO NOT USE THE TERM “RETIRED.”)

55.KIND OF BUSINESS/INDUSTRY

The information above was reviewed and found to be correct. I attest that all information is accurate and truthful. I understand that it is a felony to willfully or intentionally supply false information.

__________________________________________________

_____________________

Signature of Informant Required

Date Required

The collection and reporting to DHEC of information contained on the South Carolina Death Certiicate are exempt from HIPAA regulations

(see 45 CFR §§ 160.203 (c), 164.512 (b) (1). However, state law provides protection against the unauthorized release of conidential information from the death certiicate.

For DHEC Use Only

State File # ________________ Date of Death __________________

DHEC-0670C (12/2015)

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2. Immediately after the last selection of fields is filled out, go on to enter the suitable details in all these - DECEDENTS EDUCATION Check the, DECEDENT OF HISPANIC ORIGIN Check, th grade or less, thth grade no diploma, High school graduate or GED, Some college credit but no degree, Associate degree eg AA AS, No not SpanishHispanicLatinoLatina, Yes Mexican Mexican American, Yes Puerto Rican, Yes Cuban, Bachelors degree eg BA AB BS, Yes other, DECEDENTS RACE Check one or more, and White Black or African American.

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