South Carolina Certificate of Death

South Carolina Certificate of Death
Include AKAs, if any. (First, Middle, Last)
Months / Days
Hours / Minutes
City and State or Foreign Country

Residence

Name prior to first marriage
First, Middle, Last
First, Middle, Last
(Name of cemetery, crematory, other place)
Check the box that best describes the highest degree or level of school completed at the time of death.
Check the box that best describes whether the decedent is Spanish/Hispanice/Latino/Latina. Check the
Check one or more races to indicate what the decedent considered himself or herself to be.
Indicate type of work done during most of working life. DO NOT USE THE TERM "RETIRED".

The information above was reviewed and found to be correct. I attest that all information is accurate and truthful. I understand that it is a felony to willfully or intentional supply false information.

The collection and reporting to DHEC of information contained on the South Carolina Death Certificate are exempt from HIPAA regularations (see 45 CFR 160.203 (c), 164-512 (b)(1). However, state law provides protection against the unauthorized release of confidential information from the death certificate.

For DHEC Use Only

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