Form Dhec-0670c - South Carolina Certificate Of Death - Funeral Home Worksheet

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SOUTH CAROLINA CERTIFICATE OF DEATH

FUNERAL HOME WORKSHEET

1. DECEDENT’S LEGAL NAME (Include AKAs, if any) (First, Middle, Last)

2. SEX

3. SOCIAL SECURITY NUMBER

4a. AGE-Last Birthday

4b. UNDER 1 YEAR

4c. UNDER 1 DAY

5. DATE OF BIRTH

6. BIRTHPLACE (City and State or Foreign Country)

(Years)

(MM/DD/YYYY)

Months

Days

Minutes

Hours

7a. RESIDENCE-STATE

7b. COUNTY

7c. CITY OR TOWN

7d. STREET AND NUMBER

7f. ZIP CODE

7e. APT. NO.

7g. INSIDE CITY LIMITS?

Yes

8. EVER IN US

9. MARITAL STATUS AT TIME OF DEATH

10. SURVIVING SPOUSE’S NAME (Name prior to first marriage)

ARMED FORCES?

Married

Married, but separated

Widowed

Yes

Divorced

Never Married

Unknown

11. FATHER’S NAME (First, Middle, Last)

12. MOTHER’S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)

13a. INFORMANT’S LEGAL NAME

13c. MAILING ADDRESS (Street and Number, City, State, Zip Code)

13b. RELATIONSHIP TO DECEDENT

18. METHOD OF DISPOSITION

Burial

Cremation

19. PLACE OF DISPOSITION (Name of cemetery, crematory, other place)

Donation

Entombment

Removal from state

Other (Specify) ________________________________________

20. LOCATION-CITY, TOWN, AND STATE

51. DECEDENT’S EDUCATION -

Check

52. DECEDENT OF HISPANIC ORIGIN? Check the box that

53. DECEDENT’S RACE- Check one or more races to

the box that best describes the highest

indicate what the decedent considered himself or herself to be.

best describes whether the decedent is Spanish/Hispanic/

degree or level of school completed at the

Latino/Latina. Check the “No” box if decedent is not Spanish/

White

time of death.

Hispanic/Latino/Latina.

Black or African American

8th grade or less

American Indian or Alaska Native

Spanish/Hispanic/Latino/Latina

No, not

(Name of the enrolled or principal tribe ) _________________

9th-12th grade; no diploma

Asian Indian

Yes, Mexican, Mexican American, Chicano/Chicana

Chinese

High school graduate or GED completed

Filipino

Yes, Puerto Rican

Some college credit, but no degree

Japanese

Yes, Cuban

Korean

Associate degree (e.g., AA, AS)

Vietnamese

Yes, other

Spanish/Hispanic/Latino/Latina

Bachelor’s degree (e.g., BA, AB, BS)

Other Asian (Specify) ________________________________

Master’s degree (e.g., MA, MS, MEng,

Native Hawaiian

(Specify) _________________________________

MEd, MSW, MBA)

Guamanian or Chamorro

Doctorate (e.g., PhD, EdD) or Profes-

Samoan

sional degree (e.g., MD, DDS, DVM,

Other Pacific Islander (Specify)_________________________

LLB, JD)

Other (Specify)______________________________________

54. DECEDENT’S USUAL OCCUPATION (Indicate type of work done during most of working life. DO NOT USE THE TERM “RETIRED.”)

55. KIND OF BUSINESS/INDUSTRY

The information above was reviewed and found to be correct. I attest that all information is accurate and truthful.

I understand that it is a felony to willfully or intentionally supply false information.

__________________________________________________

_____________________

Signature of Informant Required

Date Required

The collection and reporting to DHEC of information contained on the South Carolina Death Certificate are exempt from HIPAA regulations

(see 45 CFR §§ 160.203 (c), 164.512 (b) (1). However, state law provides protection against the unauthorized release of confidential information from the death certificate.

For DHEC Use Only

State File # ________________

Date of Death __________________

DHEC-0670C (12/2015)