Marshall County Coroner's Office Cremation Permit Request

Marshall County Coroner's Office Cremation Permit Request

ALABAMA UNIFORM CREMATION REQUEST
This request for cremation shall only be made to the Coroner of the county where the sequence of events began that ultimately resulted in the death.
ALL FIELDS ARE REQUIRED
Decedent Information
Decedent Name *
Age *
Race *
Sex *
Date of Birth *

Month Day Year
Date
SSN *
Date & Place of Death
Date of Death *

Month Day Year
Date
Time of Death *
Place of Death (facility name/address) *
Address *

Address

Street Address Line 2

City State

Zip
Authorizing Agent Information
Authorizing Agent *
Relationship *
Address *

Address

Street Address Line 2

City State

Zip
Phone *
Medical Certifier & Medical Information
Person Certifying Death *
Phone *
Medical Facility/Practice Name *
City *
State *
Zip *
Manner of Death (if known) *
Cause of Death (if known) *
Circumstances Surrounding Death e.g. disease, injury/trauma, motor vehicle collision, suspected overdose, etc *
Circumstances Surrounding Death e.g. disease, injury/trauma, motor vehicle collision, suspected overdose, etc *

HOSPICE DEATH INPATIENT DEATH HOME DEATH CORONER CASE
Requesting Funeral Home
Mortuary/Funeral Home Requesting *
Phone *
Address *

Address

Street Address Line 2

City State

Zip
Funeral Director Acknowledgement
Pursuant to Code of Alabama 22-9A-16, I certify that the information contained herein is true and accurate.
Funeral Director *
Funeral Director Signature *
Typing Name in Signature Line Constitute Signature
Today's Date (Automatic)

Month Day Year
Date
Authorization Reply via Email or Fax to *
example@example.com
Date Received

Hour Minutes
Date Received

Month Day Year
Date
Should be Empty:

Marshall County Coroner's Office Cremation Permit Request

ALL FIELDS ARE REQUIRED

Decedent Information

Date & Place of Death

Authorizing Agent Information

Medical Certifier & Medical Information

Requesting Funeral Home

Funeral Director Acknowledgement