Indigent_Funeral_Referral_(Pinellas_County)_watermarked_.pdf
PDF 933 KB Posted
- Attached to
- Indigent Burial and Cremation Services
- Solicitation number
- 26-0292-RFP
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This is an Indigent Cremation Referral Form utilized by Pinellas County, Florida, to process deceased individuals requiring county-funded burial or cremation services. The form captures essential information about the deceased, including full name, Social Security number, date of birth and death, demographic details, cause of death, address history, and veteran status. It also documents eligibility for Social Security death benefits, family consent preferences regarding burial or cremation, body condition assessment, next-of-kin contact information, and additional relevant details. The form includes checkboxes for autopsy authorization and body condition categorization (good, infectious, or deteriorated), along with fields for recording family consent regarding anatomical board involvement. The document is administered through the Pinellas County office located at 440 Court Street, 2nd Floor, Clearwater, Florida 33756, with contact available at (727) 464-3000.
This referral form serves as the operational intake document supporting the competitive indigent burial and cremation services procurement (RFP 26-0292-RFP), which anticipates approximately 1,060 annual calls for service and 720 claimed and unclaimed human remains requiring disposition, comprising 650 adults, 50 veterans, and 20 stillborn or infant cases. The form's data collection requirements align directly with the scope of services specified in the RFP, enabling systematic processing of eligibility determinations and service routing. The referral information feeds into the county's contracted provider network, with proposals due April 14, 2026, and the five-year contract term commencing upon award. Annual funding for indigent burial and cremation services does not exceed $550,000, with pricing capped at $30,000 total annual bid amount.
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Text version
Indigent Cremation Referral
Information of Deceased:
Name: _________________________________________ Social Security Number: ___________________
Date of Birth: _______________ Date of Death: _______________ Sex: M ___ F ___ Race: ___________
Cause of Death: _____________________________________________ Date of Obituary: ______________
Marital Status: Single ___ Divorced ___ Widow(er) ___ Married ___ Name of Spouse: __________________
Address at Time of Death: ________________________________________________________________________ (Street)
(City) (State) (Zip Code) (Phone Number)
Previous Address (if applicable): _____________________________________________________________ (Street)
(City) (State) (Zip Code) (Phone Number)
Veteran: Yes ___ No ___ Eligible for Social Security Death Benefit: Yes ___ No ___
Contact Person for Deceased – Relative, Friend, Guardian (required for a Minor Parent):
Name: __________________________________________ Social Security Number: _________________
Relationship to Deceased: _____________________________
Address: _________________________________________________________________________________ (Street) (City, State) (Phone Number)
Family Consent / Anatomical Board: Yes ___ No ___ Burial ___ Cremation ___
Body Condition: Good ___ Infectious ___ Deteriorated ___ Autopsy ___
Additional Information: _____________________________________________________________________
440 Court Street, 2nd Floor, Clearwater, Florida 33756 Ph: (727) 464-3000
Vendor
SAMPLE
Sara.Hadden Cross-Out
Brea Templeton Cross-Out
| Date of Obituary: |
| Name of Spouse: |
| Previous Address if applicable 1: |
| Previous Address if applicable 2: |
| Zip Code_2: |
| Phone Number_2: |
| Additional Information 1: |
| Additional Information 2: |
| Additional Information 3: |
| Check Box5: Off |
| Check Box6: Off |
| Check Box7: Off |
| Check Box8: Off |
| Check Box9: Off |
| Check Box10: Off |
| Check Box11: Off |
| Check Box12: Off |
| Check Box13: Off |
| Check Box14: Off |
| Check Box15: Off |
| Check Box16: Off |
| Check Box17: Off |
| Check Box18: Off |
| dec_FullNameWSuffix: |
| dec_DOB_MMDDYYYY_DropLeadZeros: |
| dec_GenderFemale_X: Off |
| dec_GenderMale_X: Off |
| dec_SSN_WithDashes: |
| decdeath_DOD_MMDDYYYY_DropLeadZeros: |
| dec_Race: |
| dec_Addr1Addr2AptSuite: |
| dec_City: |
| dec_Zip: |
| dec_Phone: |
| causes_CauseA: |
| dec_MilitaryYes_X: Off |
| dec_MilitaryNo_X: Off |
| nok_CompleteName1: |
| nok_SSN1: -- |
| nok_RelationshipToDeceased1: |
| nok_Address1: |
| nok_CSZ1: |
| nok_Phone1: |
File details come from the government source that posted it. Updated .