Death Certificate Worksheet

Disclaimer
Privacy Notice

Read our privacy commitment
Our Commitment to Your Privacy

At Safe Harbor Funeral Service, we understand the deeply personal and sensitive nature of the information you share with us during this difficult time. We are committed to protecting your privacy and handling your confidential information with the utmost care and respect.

Information We Collect

In order to provide our services, we collect necessary personal and confidential information, which may include details about the deceased, family contacts, financial information for billing purposes, and other relevant data required for funeral arrangements.

How We Protect Your Information

While funeral homes are not covered entities under the Health Insurance Portability and Accountability Act (HIPAA), we uphold stringent privacy practices that align with the spirit of data protection and privacy regulations. We maintain physical, electronic, and procedural safeguards to protect your non-public personal information. Access to your information is restricted to employees who need it to provide our services to you.

We do not share your confidential information with third parties except as necessary to fulfill the services you have requested (e.g., florists, cemeteries, clergy), as required by law, or with your explicit consent.

Your Trust is Our Priority

Your trust is paramount to us. If you have any questions or concerns about our privacy practices, please do not hesitate to contact us.
Acknowledgment

Death Certificate Worksheet
The information entered here will be provided to the health department to aid in generating a death certificate and permit for burial/cremation.
1. Legal Name (Include ADA's if any) First: First Name* Middle: Middle Last: Last Name*
2. Sex

MaleFemale
3. Birthdate*

MonthDayYear
Date
4. Birthplace: City or Town County
5. State or Foreign County
6. Was Decedent ever in military

YesNoUnknown

10. Residence
11. City or Town
12. Residence County
13. Tribal Reservation Name (if App)
14. State or Country
15. Zip code + 4
16. Inside City Limit

YesNoUnknown
17. Years at residence
18. Marital Status at Time of Death
19. Surviving Spouse's Name (Give name prior to first marriage)

20. Occupation
21. Kind of Business/Industry (Do not use company name)
22. Father's Name Father's First Name Father's Middle Name Father's Last Name Suffix
23. Mother's Last Name Before first marriage Mother's Maiden Name

24. Informant's Name*
25. Relationship to Decedent*
26. Informant's Email*
example@example.com
27. Informant's Phone*
Please enter a valid phone number.
Should be Empty:

Disclaimer

Death Certificate Worksheet