verification of death
Alabama Department of Public Health
On the basis of examination and/or investigation, in my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated..
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Confirmation of Death Form (DT) (pdf)
What information was used to verify this patients death? (Upload source(s) into REDCap.) (Check all that apply.) □ Medical Record. □ Death Certificate. □
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Form 1310 (Rev. August 2014)
Name of decedent. Date of death. Decedents social security number. Name of person claiming refund. Your social security number. Home address (number and street)
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