DECEASED NAME
If HospitalInpE.R.DOA
Hispanic Origin
YesNo
SexMaleFemale
Marital StatusMarriedDivorcedSingleWidowed
Inside City LimitsYesNo
AutopsyYesNo
Referred to CoronerYesNo
I certify that the above information is correct (signature in box)
[signature signature-certify]
Picture YesNo
Survivors (Name and Place of Residence)
Picture Upload
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