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 for Pinellas County, Florida, designed to collect comprehensive information about deceased individuals requiring indigent funeral services. The form captures essential data including the decedent's personal information (name, Social Security number, date of birth and death, gender, race, and cause of death), residential addresses, veteran and Social Security death benefit eligibility status, next-of-kin contact information, family consent preferences regarding burial or cremation, and body condition assessment. The form also includes fields for documenting anatomical board authorization and additional relevant information. This referral document serves as the intake mechanism for Pinellas County's indigent burial and cremation services procurement, which seeks to process approximately 1,060 calls for service annually with an estimated 720 claimed and unclaimed human remains requiring disposition. The related RFP 26-0292-RFP solicits qualified providers to deliver these services, with proposals due on April 14, 2026, at 3:00 PM via the OpenGov procurement website. The resulting contract will have a five-year term from the date of award with no scheduled site visits or pre-conference meetings.
Qualified bidders must hold a current Florida funeral director license, maintain an FDEP-certified incinerator facility, provide refrigerated storage capacity for up to 100 concurrent bodies, and demonstrate a minimum of five years of experience providing similar services to governmental organizations. The annual funding estimate does not exceed $550,000, with pricing capped at a total annual bid amount of $30,000 and all submitted pricing required to remain fixed regardless of actual case volume variations. Proposers must comply with multiple affidavits including Foreign Countries of Concern, Human Trafficking, and Common Carrier attestations, as well as execute a HIPAA Business Associate Agreement. Required insurance coverage includes commercial general liability of $1,000,000, professional liability of $1,000,000, and workers' compensation insurance as mandated by Florida law. The solicitation is open to all qualified providers meeting minimum qualifications with no reported set-asides for disadvantaged enterprises, and no incumbent vendor information is referenced in available documentation.
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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 .