Funeral Home Facility Inspection Checklist Form 002 HAS 646.pdf

VA Pittsburgh Healthcare System Health Administration Services (136-A)

1010 Delafield Road Pittsburgh, PA 15215

Funeral Home Facilities Inspection Checklist

Date

Veteran SSN

Name of Funeral Establishment

PREPARATION OF BODY FOR BURIAL

1.Embalming of body completed Completed Date Completed

Notes

2. Body washed and nails are clean. Completed Notes

3. Dressed in undergarments, suit, shirt and tie for a male and undergarments, hose and dress for female.

Completed Notes

4. Cosmetizing completed and hair appropriately styled.

Completed Notes

5. Remains placed in a casket in a manner that creates an appearance of rest and ensures maintenance of position during transport.

Completed Notes

6. Casket of sufficient size to prevent the appearance of crowding and cramping.

Completed Notes

7. Casket, at a minimum, is constructed from thick, strong particle board and must be sufficient strength to support the weight of an adult human body.

Completed Notes

8. Casket is lined and the exterior contains handles to aid in movement.

Completed Notes

9. Head is appropriately positioned on a pillow. Completed Notes

Form No. 002-HAS (646) 1/2015

10. If the scalp was shaved due to medical treatment, the cranium was wrapped with gauze or equivalent in a neat and professional manner.

Completed N/A

Notes

11. Mutilated hands-will be treated by either wrapping with gauze or by placing gloves on hands.

Completed N/A

Notes

ESTABLISHMENT-EXTERNAL APPEARANCE

1. BUILDING- Exterior appears to be clean and well maintained.

Completed Notes

2. GROUNDS- Grounds and parking areas appear to be well maintained.

Completed Notes

3. LOCATION-Surrounding area appears to be well-maintained and comparable to areas surrounding majority of local funeral homes.

Completed Notes

We, the undersigned, certify that the funeral home named above is ( ) is not ( ) acceptable by the Department of Veterans Affairs to provide contractual mortuary services.

Mortuary Officer

Date

Chief, HAS or VA Representative

Date

Form No. 002-HAS (646)

1/2015