Internship Funeral Arrangement Case Report Form - Minnesota Department Of Health
ADVERTISEMENT
1
2Minnesota Department of Health
Internship Funeral Arrangement Case Report Form
Mortuary Science Section
Minnesota Department of Health
P.O Box 64882 St. Paul, MN 55164-0882
Telephone: 651-201-3829 Fax: 651-201-3839
Email: Health.Mortsci@state.mn.us
Indicate your involvement by placing a check mark in front of the tasks below that you have actively
participated and completed.
First Call
____
Obtain NOK signature(s) on Cremation
____
Received first call information:
Authorization
-Gender:________________________________
____
File Family Cremation Authorization
-Age:__________________________________
____
Fax Cremation Authorization to physician
-Place of death:__________________________
____
Fax Cremation Authorization to ME for
-City of death:___________________________
approval
-County of death:_________________________
____
Notify physician to complete death record
-Cause of death:__________________________
____
Fax death worksheet to physician to complete
-Notified of death by:_____________________
____
Fax complete death worksheet with COD to
____
Replenish removal vehicle
Vital Records
____
Remove and transport deceased to FH
____
Complete Certificate of Removal
Merchandise Selection & Ordering
-Date of removal:_________________________
-Time of removal:________________________
____
Offer and discuss the selection of merchandise
____
Schedule arrangement conference with NOK
-Name of casket:_________________________
____
Greet NOK at arrangement conference
-Name of casket manufacturer:______________
-Number of NOK attending arrangements:____
-Date of casket order:_____________________
-Legal NOK relationship:__________________
-Name of urn:___________________________
-Name of urn manufacturer:________________
-Date of urn order:________________________
Process &File Records
-Name of outer burial container:_____________
____
Collect vital statistic information
-Name of vault company:__________________
____
Input vital statistics into MR&C
-Date of vault order:______________________
____
File disposition permit
-Name of monument company:______________
____
File death certificate
-Type of monument:______________________
____
Present GPL to NOK
-Date of monument order:__________________
____
Write obituary notice
____
Submit obituary notice to local newspaper
Cash Advanced Item Selection & Ordering
-Name of newspaper:______________________
____
File forms for veteran benefits:
____
Offer and discuss cash advanced items
___
Arrange for Military Honors
-Name of escort company:__________________
___
File Veteran Monument Application
-Number of escort(s):_____________________
___
File application for United States Flag
-Name of florist:_________________________
___
Obtain United States Flag
-Number of floral arrangement(s):___________
____
File forms for Social Security benefits
-Number of death certificate(s) ordered:______
____
File for Crime Victim Reparation Board benefits
-Name of crematory:______________________
____
File for county benefits
-Name of cemetery:_______________________
-Name of county:_________________________
____
Order cemetery equipment
____
File forms for Insurance co.
___
Lowering device
-Name of Insurance co.____________________
___
Tent
___
File Claimant forms
___
Chairs
___
File Assignment forms
___
Outer burial container
____
File Embalming Authorization
List other:______________________________
Funeral Arrangement Case Report#(1-25):___________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal