Death Notification
LEGAL REQUIREMENTS OF NOTIFICATION. In accordance with Alabama state law, 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. The on-call investigator for the Coroner's Office may be reached at (256) 568-8900.
INFORMATION ON THE PATIENT
Patient's (Decedent's) Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
INFORMATION ON THE DEATH
Date & Time of Death
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Manner of Death
*
Please Select
Natural
Homicide*
Suicide*
Accident*
Unknown*
*ANY MANNER OTHER THAN "NATURAL" MUST BE REPORTED TO THE ON-CALL DEATH INVESTIGATOR
Primary Cause of Death
*
Circumstances Surrounding Death
(Ex: disease, injury/trauma, motor vehicle collision, suspected overdose, etc.)
INFORMATION ON CERTIFIER/PCP/PROVIDER
Doctor Certifying the Death
*
First Name
Last Name
Medical Facility Where Death Occurred
*
CASE INFORMATION
How did the patient arrive at the hospital (if EMS, provide the agency)
*
Did you contact the on-call official? Remember to read the "legal requirements of notification" at the top of the page.
*
Yes
No
If a law enforcement agency was involved at any point during the patients care, please indicate which agencies:
Alabama State Fire Marshalls Office
Alabama State Troopers
Albertville Police Department
Arab Police Department
Boaz Police Department
Guntersville Police Department
Marshall County Sheriff's Office
State Bureau of Investigation
Other
INFORMATION ON PERSON SUBMITTING NOTIFICATION
Notifier Name (Person Submitting This Notification)
*
First Name
Last Name
Email
*
example@example.com
Direct Phone Number
*
Please enter a valid phone number.
IMPORTANT: YOU MUST ACKNOWLEDGE BY ENTERING YES OR NO
If you are unable to acknowledge any of the statements below you must contact the on-call death investigator (256) 568-8900 Ext. 800.
Is the death a result of a drug overdose?
Yes
No
Is the death a result of physical injury (fall, MVA, assault, etc)
Yes
No
Does the decedent show signs of abuse or neglect?
Yes
No
Does the death appear suspicious or possibly criminal?
Yes
No
IF YOU ANSWERED YES TO ANY OF THE QUESTIONS ABOVE, YOU MUST CONTACT THE ON-CALL INVESTIGATOR. ALL UNNATURAL DEATHS MUST BE REPORTED.
ACKNOWLEDGEMENT
By submitting this notification you are acknowledging that you have read and understand the statement at the top of this page. In typing your name below you are acknowledging this statement.
Type your name to represent your signature
*
Date & Time Submitted
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: