First Call Intake

1Call information

Date Time Taken by

Location

Full legal name Maiden / other name

Date of birth Gender Est. weight (lb)

Age

—

Date of death Time of death

SSN

Only the last 4 digits are kept when a call is saved.

Facility type Facility name Room / Apt #

Street address City

State ZIP Facility phone

Cleared for removal? Yes No Other

Removal considerations Steps Tight space Extra staff

Removal instructions

Caller name Relationship Primary phone

Is the caller the next of kin? Yes No

Attending physician Hospice agency County coroner

Intended disposition Burial Cremation Donation Transfer out of state

Embalming permission Verbal granted Refused Hold / discuss later

Pre-arrangements? Yes No Unknown

Staff dispatched

Personal effects None Accompany decedent Remain at facility Other (see below)

Instructions / description

Contact family tonight? Yes No, a funeral director will call tomorrow

Notes

Staff completing form Date