|
1. |
Name
and address of the deceased. |
8. |
Location of the deceased.
|
|
2. |
Age,
race, sex, date of birth,
and marital status.
|
9. |
Time of death. Hour and date.
|
|
3. |
Occupation of the deceased. |
10. |
Name
of person reporting the death.
|
|
4. |
Address and telephone number
for next-of-kin.
|
11. |
Name
of physician who pronounced death.
|
|
5. |
Time
of accident or onset of cause
of death. Hour and date.
|
12. |
Name
of attending physician. |
|
6. |
Place,
mode, and manner of injury.
|
13. |
Any
other pertinent information. Such as circumstances
surrounding the death. |
|
7. |
Place
of death. |
|
|