Test-Death Certificate Worksheet Form

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Privacy Notice

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.
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Acknowledgment* This field is required.
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The information entered here will be provided to the health department to aid in generating a death certificate and permit for burial/cremation.
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1. Legal Name (Include ADA's if any) First: First Name * Middle: Middle Last: Last Name *
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2. Sex
Male
Female
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3. Birthdate* This field is required.
Date
Month
Day
Year
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4. Birthplace: City or Town County
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5. State or Foreign County
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6. Was Decedent ever in military
Yes
No
Unknown
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7. Decedent's Education
8th grade or less(specify)
Master's Degree
9th to 12th no diploma
Associate Degree
High School Grad or GED
Bachelor's Degree
Some college, no degree
Doctorate or Prof. degree
Other (please specify)
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Other Enter details here
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8. Was Decedent of Hispanic Origin? (Check the box that best describes whether the decedent was Spanish/Latino or check the "No" box if decedent was not Spanish/Hispanic/Latino).
No, Not Spanish/Hispanic/Latino
Yes, Mexica, Mex/Amer, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other Spainish/Hispanic/Latiino
Other ( please specify)
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OtherEnter details here
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9. Decedent's Race (s) 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)
Asian Indian
Chinese
Filipino
Japanese
korean
Vietnamese
Other Asian (specify)
Native Hawaiian
Guamanian or Chmorro
Samoan
Other Pacific Islander (specify)
Other (please specify)
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SpecifyEnter details
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10. Residence
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11. City or Town
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12. Residence County
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13. Tribal Reservation Name (if App)
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14. State or Country
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15. Zip code + 4
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16. Inside City Limit
Yes
No
Unknown
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17. Years at residence
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18. Marital Status at Time of Death
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19. Surviving Spouse's Name (Give name prior to first marriage)
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20. Occupation
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21. Kind of Business/Industry (Do not use company name)
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22. Father's Name Father's First Name Father's Middle Name Father's Last Name Suffix
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23. Mother's Name Before first marriage Mother's First Name Mother's Middle Name Mother's Last Name
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24. Informant's Name* This field is required.
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25. Relationship to Decedent* This field is required.
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26. Informant's Email* This field is required.
example@example.com
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27. Informant's Phone* This field is required.
Please enter a valid phone number.
Should be Empty: