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Jackson County Medical Examiner's Office - Report of Nursing Home or Hospice Death

  1. NOTE: To submit this form you do not have to sign in or create a Jackson County Form Center account above. However, you will have to complete the form in its entirety without the option to save your progress unless you do create an account.

    Thank you.

  2. Jackson County Medical Examiner's Office

    Phone: 816-881-6604 Fax: 816-881-6598

  3. If recent or remote injury CONTRIBUTED to the death, please call 816-881-6604 to report the death.

  4. Nursing Home Death?*

  5. Hospice Death?*

  6. Decedent Information

  7. Sex*

  8. Agency Information

  9. Death Details

  10. Death Witnessed or Found*

  11. If Found: Last Known Alive/Alert (LKA)

  12. Funeral

  13. Relative of Decedent

  14. Cause of Death

  15. Cardiovascular Disease

  16. If YES check all that apply

  17. Seizures

  18. If YES check all that apply

  19. Cirrhosis

  20. If YES check all that apply

  21. Mental Illness

  22. If YES check all that apply

  23. Pulmonary Disease

  24. If YES check all that apply

  25. Diabetes

  26. If YES check one

  27. Cancer - Metastic

  28. Chronic Kidney Disease

  29. Other Illness

  30. Recent Surgery

  31. Any recent or remote injury/trauma that are either the cause of death or a contributing factor?

  32. If answer to either of these questions is yes, please call 816-881-6604 to report death.

  33. Was there any recent or remote injury which is considered by the physician NOT to have contributed to the death?

  34. Please print a copy for your records. The Medical Examiner's Office may contact the reporting person or the physician with additional questions.

  35. Leave This Blank:

  36. This field is not part of the form submission.