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 used by Pinellas County, Florida, to document and process deceased individuals who qualify for indigent burial and cremation services. The form collects comprehensive information about the deceased, including personal identifiers, date and cause of death, last known address, veteran status, Social Security death benefit eligibility, and body condition assessment. The document also captures contact information for the next of kin or legal representative and documents family consent regarding the method of disposition—burial or cremation. The form is completed by county staff or designated vendors and submitted to the Pinellas County administration office located at 440 Court Street, 2nd Floor, Clearwater, Florida 33756.
This referral form serves as the intake document for the competitive indigent burial and cremation services contract (RFP 26-0292-RFP), which anticipates approximately 1,060 calls for service annually with an estimated 720 claimed and unclaimed human remains requiring disposition. The contract encompasses 650 adult cases, 50 veteran cases, and 20 stillborn or infant cases annually. Qualified service providers must hold a current Florida funeral director license, maintain an FDEP-certified incinerator facility, provide refrigerated storage for up to 100 concurrent bodies, and demonstrate a minimum of five years of governmental contract experience. The contract term is five years from the date of award, with proposals due April 14, 2026, at 3:00 PM via the OpenGov procurement website. Annual funding is capped at $30,000 with a maximum estimate not to exceed $550,000, and pricing must remain fixed regardless of actual case volume fluctuations. Prospective bidders must carry $1,000,000 in both commercial general liability and professional liability insurance, execute required affidavits regarding foreign countries of concern and human trafficking compliance, and sign a HIPAA Business Associate Agreement.
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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 .