First Call Gathering Sheet

First Call Gathering Sheet

6839 Braddock Road, Annandale, VA 22003
**STOP**

If the person dies at home or nursing home a hospice nurse or police MUST give you the permission to remove the body from the residence.

Ask - was hospice or the police notified?

If NO, you must advise family to call them first. If under hosapice, they MUST call the hospice nusrse first.

IF NOT under hospice care they must call 911.
Report a death by:

Other
Callers Name:

First NameLast Name
Time of call:

Hour Minutes

AM/PM Option
Name of Deceased:

First NameLast Name
Date of Birth / Date of Death:

DOBDOD
Name of Location:
Where human remains are located to be removed
Phone Number of Location:
Please enter a valid phone number.Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
BELOW INFORMATION NOT GIVEN BY FAMILY

ASK THE HOSPICE, POLICE OR HOSPITAL TO PROVIDE.
Name of the doctor to sign Death Certificate:

First NameLast Name
Time of Death:

Hour Minutes

AM/PM Option
Phone Number to doctors office:
Please enter a valid phone number.Format: (000) 000-0000.
Approx. Weight of deceased:
If at home, how many step:
Location of deceased i.e floor, hospital bed. Etc.
NOTE: THE WEIGHT AND STEPS ENSURES, TO SEND THE APPROPRIATE TEAM.
Is family present?
Is the Family ready for us to come?
PLEASE NOTE

Our standard arrival time is 90 minutes to 2 hours. Depeneds on the Mile and Traffic.
Who is next of Kin: (Define KIn: A person's relative)

First NameLast Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
1. Written directive
2. Surviving competent spouse or domestic partner (as defined)
3. Sole surviving competent adult child, or the majority of competent surviving 4. adult children
4. Surviving competent parent(s)
5. Surviving competent adult in the next degree of kinship
6. Competent adult friend or volunteer
I verbally authorize Mustafa Center Funeral Home to embalm the human remains of the deceased listed above for international travel.
If Yes, ( Destination)
Name of the person receiving the call.
Should be Empty: