Form Dhec 670C PDF Details

Form Dhec 670C is a vital document for South Carolina businesses. This form must be filed annually with the Department of Health and Environmental Control to certify that your company is in compliance with all state environmental regulations. Failing to file this form can result in penalties and fines, so it's important to make sure you understand and comply with all filing requirements. Here we'll provide an overview of what you need to know about Form Dhec 670C.

QuestionAnswer
Form NameForm Dhec 670C
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names12th, 2004, DDS, 23b

Form Preview Example

SOUTH CAROLINA CERTIFICATE OF DEATH

WORKSHEET

DATE OF DEATH: (MM/DD/YYYY)_______________________

 

 

1. DECEDENT'S LEGAL NAME (Include AKA's, 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 (If wife, give name prior to first 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 NAME

 

 

 

13b. RELATIONSHIP TO DECEDENT

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. PLACE OF DEATH (Check only one: see instructions)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF DEATH OCCURRED IN A HOSPITAL:

 

 

 

IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL: Hospice facility

 

 

 

Inpatient

Emergency Room/Outpatient

Dead on Arrival

 

Nursing home/Long term care facility

Decedent's home

Other (Specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. FACILITY NAME (If not institution, give street and number)

16. CITY OR TOWN, STATE, AND ZIP CODE

 

 

17. COUNTY OF DEATH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. METHOD OF DISPOSITION

Burial

Cremation

 

 

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

 

 

 

Donation

 

Entombment

Removal from State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (Specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. LOCATION-CITY, TOWN, AND STATE

 

 

 

 

 

21. NAME AND ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OF FUNERAL FACILITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22. SIGNATURE OF FUNERAL SERVICE LICENSEE OR OTHER AGENT

23. LICENSE NUMBER (Of Licensee)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23a. EMBALMER (Signature)

 

 

 

 

 

 

 

 

 

23b. EMBALMER LICENSE NUMBER

23c. LICENSE NUMBER (Of Facility)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Associates 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 Professional degree (e.g., MD, DDS, DVM, LLB, JD)

52.DECEDENT OF HISPANIC ORIGIN? -Check the box that best describes whether the decedent is

Hispanic/Latino/Latina. Check the "No" box if decedent 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

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 Pacific Islander (Specify)

Other (Specify)

BRTP NO.

54.DECEDENT'S USUAL OCCUPATION (Indicate type of work done during most of working life. DO NOT USE THE TERM

55.KIND OF BUSINESS/INDUSTRY

The information above was reviewed and found to be correct:

(Signature of informant) (Not Required)

(Date)

The collection and reporting to DHEC of information contained on the South Carolina Death Certificate are exemot from HIPAA regulations.

(see 45CFR§§160.203(c),164.512(b)(1).However, state law protection against the unauthorized release of confidential information from the death certificate. DHEC 670C(07/2004)

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