Attachment_B.pdf
PDF 239 KB Posted
- Attached to
- Burial and Cremation Services
- Solicitation number
- Y22-157
- Issued by
- Orange County, Orlando City, Florida
About this file
This document is a Request for Public Burial or Cremation Services form from Orange County Family Services in Orlando, Florida, designed for cases involving unclaimed bodies or indigent deceased individuals who require public burial or cremation services. The form is part of Orange County's Public Burial & Cremation Program and is used to document and request public funding for disposition of remains when no family can be located or the family lacks financial resources. The form allows funeral homes to certify the circumstances surrounding an unclaimed or indigent deceased person and request county-funded burial or cremation services.
The form includes multiple checkbox options to document specific circumstances, such as whether the deceased is unidentified, if the Anatomical Board of Florida has been notified, whether family cannot be located, or if the family has been advised of the death and declined to claim the body. The document requires details about the deceased, including name, social security number, date of birth, date of death, race/sex, and last known address. The form also captures information about potential veteran status and available resources, with Waldon Funeral Home listed as the contract service provider. The form is dated January 22, 2016, and is to be submitted to Orange County Family Services Department at 2100 East Michigan Street in Orlando, Florida.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Attachment_A.pdf | ||
| IFB_#Y22-157-KK_Burial_and_Cremation_Services.pdf |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
REQUEST for PUBLIC BURIAL or CREMATION SERVICES
By submitting this request form to Orange County Family Services, the requestor is certifying that the deceased person named here requires burial or cremation at public expense by Orange County because of being an unclaimed body since no family has been located and/or the deceased and the existing family is indigent.
The Deceased: ___________________________________________________ Date/Time Faxed: _______________________
Name: _________________________________________________________ SSN: _________________________________
DOB: ______________ DOD:. ____________ Race/Sex: _______ Date Rec’d by Funeral Home: ______________________
Last known address: __________________________________________________________________________________________
City: ___________________________________________________ State/Zip: ______________________________________
Next of Kin or Informant Name: ____________________________________ ____ Phone #: _________________
Address: ___________________________________________________ City/State/Zip:_________________________________
Body picked up from: _________________________________________________________________________________________
Check all the items that apply: The deceased person is unidentified.
The Anatomical Board of the State of Florida has been notified of the unclaimed body and has declined to accept the body for the following reason(s): ___________________________________________________________________
Anatomical Board will accept this body.
Family CANNOT be located. The family has been advised of the county program and has agreed to cremation service.
The family has been advised of the death but has declined to claim the body.
Attachment B
No resources for burial have been identified.
Available resources are insufficient for burial. _____ Partial payment is available from: _______________________
The deceased is a veteran and IS, IS NOT eligible for burial as a veteran.
The deceased is veteran’s spouse and is eligible for space at veteran’s cemetery.
I/we certify that the information provided is accurate to the best of my/our knowledge and I/we agree to provide the contract services as outlined in the County Service Agreement. I/we agree to accept the rates paid by the County as total payment for the burial or cremation of the above named person. Payments received from any other source will be deducted from the invoice or refunded to the County.
Signed: _______________________________________ Title: ________________________________ FUNERAL DIRECTOR Date: _______________
Company: ________________________________________________________________ Phone: __________________________
WALDON FUNERAL HOME 321-363-1592
(Contract Service Provider)
Orange County Family Services Department Public Burial & Cremation Program
2100 East Michigan Street, Orlando, Florida 32806 Phone: (407) 836-6500; Fax: (407) 836-1973
(Form #1: Revised 22 January 2016)
File details come from the government source that posted it. Updated .