Hlth 3987 - Notification Of Expected Death In The Home
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1NOTIFICATION OF
EXPECTED DEATH IN THE HOME
To be completed by the Attending Medical/Nurse Practitioner
ATTENTION: FUNERAL DIRECTOR
NAME OF FUNERAL HOME
ADDRESS
CITY
PROVINCE
POSTAL CODE
This is being sent to you in anticipation of death at home in the near future. You have been identified as the funeral home of choice. The family has been
instructed to call you one hour after death has occurred for transport of the body.
As the attending medical/nurse practitioner, I certify that this person is known to me and that to the best of my knowledge and belief this is a natural and
expected death. Upon death I authorize you to transfer the body and to complete the Registration of Death. I, or my designate, will complete the Medical
Certificate of Death within 48 hours. This authorization shall be in effect for 3 months from the date signed.
PATIENT’S NAME
GENDER
DATE OF BIRTH (DD/MM/YYYY)
PERSONAL HEALTH NUMBER
M
F
ADDRESS
CITY
PROVINCE
POSTAL CODE
PRECAUTIONS, IF ANY:
NAME OF ATTENDING MEDICAL / NURSE PRACTITIONER
PRACTITIONER COLLEGE ID NUMBER
PHONE NUMBER
ADDRESS
CITY
PROVINCE
POSTAL CODE
COMMENTS
SIGNATURE OF ATTENDING MEDICAL / NURSE PRACTITIONER
DATE SIGNED (DD/MM/YYYY)
AUTHORIZATION OF DISPOSITION FOR EXPECTED DEATH AT HOME
To be completed by the person authorized to control
the disposition for the expected death at home of:
I certify that I am legally authorized to make decisions after death has
RELATIONSHIP TO DECEASED
occurred and that the plan for management of expected death at home
from the Cremation, Interment and Funeral Services Act, Sec 5 (1)):
has been discussed and agreed to. I agree to the transfer of the body from
Authorization of disposition is in order of priority as set out below.
the home without pronouncement of death by a health care professional
and that we will follow the plan by noting the time of death and agreeing
a) personal representative named in the will;
to wait at least one hour from the time of death to call the funeral home
b) spouse of deceased;
for transfer of the body. I agree to indemnify and hold harmless the Funeral
c) adult child of deceased;
Home, its employees and agents, from any liability for claims, damages,
d) adult grandchild of deceased;
costs and expenses of whatever kind or nature (except any claim arising out
of or in connection with the wilful misconduct, malfeasance, or negligence
e) if deceased a minor, legal guardian of deceased at time of death;
of the Funeral Home, its employees and agents) incurred in connection with
f) parent of deceased;
or arising from the Funeral Home dealing with the Patient’s body on my
g) adult sibling of deceased;
instructions.
h) adult nephew or niece of deceased;
i) adult next of kin of deceased, determined under sections 89
and 90 of the Estate Administration Act;
j) minister under the Employment and Assistance Act or the
printed name
official administrator under the Estate Administration Act;
k) an adult person having a personal or kinship relationship with the
deceased, other than those referred to in paragraphs (b) to (d)
signature
and (f) to (i).
date signed
contact phone number
Copy 1: Family
Copy 2: Home Health Office/Community Nursing
Copy 3: Funeral Home
HLTH 3987 2015/07/30
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