CONFIRMATION OF FACT OF DEATH

TO BE LEFT WITH THE DECEASED FOR FUNERAL DIRECTOR

NAME OF PATIENT		
ADDRESS		
DATE OF BIRTH		
OWN GP - NAME		
OWN GP- ADDRESS		

DATE OF CONFIRMATION OF DEATH		
TIME OF CONFIRMATION OF DEATH		
CONFIRMING QUALIFIED NURSE - NAME		
CONFIRMING QUALIFIED NURSE - SIGNATURE		
GP NOTIFIED OF PATIENTS DEATH		
DOES THE PATIENT HAVE ANY IMPLANTABLE
DEVICES, e.g. pacemaker or implantable cardioverter defibrillator (ICD)	YES  - state type and position NO
DON’T KNOW	
DOES THE PATIENT HAVE ANY INFECTION	YES  - state type

NO	
Name and address of funeral director to be used (if known) –	
Is the deceased for cremation?

YES	NO	Don’t Know	

THIS IS NOT A DEATH CERTIFICATE
Death certificates are obtained via the patient’s own GP.
(Version 4 September 2024)