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Notification of Death

Required notification under RSMo. 198.071.1–3. Complete this form to notify the Randolph County Coroner of a death.

Call first

This form is a written record — it does not replace calling. Contact Randolph County Dispatch at 844-277-6555 and ask to speak with the on-duty coroner.

Fields marked are required.

Hospice / Facility

Hospice company and/or facility name

Address

City

State

ZIP code

Telephone number

Deceased

First name *

Middle name

Last name *

Date of birth

Race

Marital status

Social Security number

Address

City

State

ZIP code

The Death

Location of death *

Date of death *

Time of death

Pronounced by whom?

Hospice DX with ICD-10 code

Medications accounted for and/or disposed of? YesNo

Hospice admit date

Last breath witnessed by (name and relation)

If deceased was found, who discovered them?

Date and time discovered

When was the deceased last seen alive?

Who last saw the deceased alive?

Any recent falls, fractures, or injury that contributed to death? YesNo

Please explain

Evidence of resuscitative measures? YesNo

Please explain

Was this death due to injury, accident, or unusual circumstance? YesNo

Was this death related to traumatic or accidental means? YesNo

Physician

Physician’s name

Address

City

State

ZIP code

Telephone number

Funeral Home

Funeral home name

Address

City

State

ZIP code

Telephone number

Submitted By

Your name *

Your telephone number *

Your email (for our confirmation)

Leave this field empty

This notification is emailed directly to the county coroner. It is not stored on this website.

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Randolph County Courthouse

372 Hwy. JJ
Huntsville, MO 65259
Toll Free: 844-277-6555

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