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7. CALUMET COUNTY MEDICAL EXAMINER

   CALUMET COUNTY HOSPICE DEATH REPORTING FORM

   Messages: 920-849-1467 Dispatch 920-849-2335

   Fax 920-849-1609

9. Decendent:
11. DOB:
12. DOD:
13. Time Pronounced:
15. Hospice Admit Diagnosis:
17. Registered Nurse Pronouncing Death:
19. DC Signing Physician:
20. Phone#:
22. Hospice Agency:
23. Phone#:
25. Place of Death:
27. Residence:

    1. Yes
    2. No
28. Next of Kin:
29. Phone#:
31. Funeral Home:
33. Expected Disposition:

    1. Burial
    2. Cremation
    3. Unknown

35. You are expected to contact the ME is a "Yes" is checked for any of the following questions. Call 920-849-2335 and request the ME on call to respond by phone. If you are uncomfortable with any of the circumstances surrounding the death of your patient do not hesitate to call us at the number above.

37. Is there any traumatic event in the decedent's past history which may have contributed to the terminal condition resulting in his/her deaths?

    1. Yes
    2. No

     

39. Injury with or without fracture within the last 90 days requiring medical attention:

    1. Yes
    2. No
41. There any possible cause of death other than a natural death?

    1. Yes
    2. No
43. The decedent's body going out of the state or to a funeral home more than 50 miles away?

    1. Yes
    2. No
45. The decedent's body going to be donated:

    1. Yes
    2. No
47. If no to all of the above you may release the body to the funeral home.
49. Please submit this form within 48 hours.
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