Screening Documentation Name * First Name Last Name Email * Phone (###) ### #### Date Completed MM DD YYYY Date of Death MM DD YYYY Relationship to Deceased / Next-of-kin County of Death Deceased Name Age / DOB Race Sex Weight Deceased Address Address 1 Address 2 City State/Province Zip/Postal Code Country Funeral Home Funeral Home Phone (###) ### #### Case Brief Circumstances Medical History Meds Tobacco Use / Smoking / Vaping Alcohol / Drug Use Where is the body now? / Is there a service planned? Has the death certificate been signed? Is the body embalmed? (Reliable toxicology cannot be done if body is embalmed) Are there medical records that need to be reviewed? Will there be an attorney involved? If so, who? Who is paying for the autopsy/How are they paying? Thank you, we will be in touch as quickly as possible.
