Submit Request | Jefferson County Coroner Online Services Portal

The Jefferson County Burial Program provides burial for decedents whose relatives cannot be located or the relatives are unable to make arrangements for final disposition. Jefferson County does not perform nor provide reimbursement for cremations, embalming, or memorial services.

Please complete the following fields and click the 'Submit Form' button to submit your application to our office. Fields marked with an asterisk are REQUIRED. Once the application is submitted and reviewed, a Deputy Coroner will contact you to discuss the case.

Applicant Information

Application Date

Who is Submitting This Application?

Next of KinFamilyFriendFacility/Agency/Organization

Applicant Name

Applicant Title or Relationship

Applicant or Facility Organization

Applicant Address

Applicant City

Applicant State

Applicant Zip Code

Applicant Phone

Applicant Alt. Phone

Applicant Fax

Applicant Email

Describe in detail the reason(s) the request for county burial is being made:

Decedent Information

Decedent's First Name

Decedent's Middle Name

Decedent's Last Name

Decedent's Age at Time of Death

Decedent's Race

Decedent's Sex

MaleFemaleUnknown

Decedent's Date of Birth

Decedent's Social Security Number

Decedent's Weight

Decedent's Height

Additional Decedent Information (required for death certificate - if unknown, type UNKNOWN in field)

Last Name Prior to First Marraige

Birthplace (State or Foreign Country)

Occupation (Indicate type of work done during most of working life, Do Not Use Retired)

Kind of Business/Industry

Surviving Spouse (Name prior to first marriage)

Ever in Armed Forces? (Yes or No)

YesNoUnknown

Decedent Residence – Street Address (Apt, Lot, Unit – if applicable)

Decedent Residence – City, Town or Location

Decedent Residence – Zip Code

Decedent Residence – Inside City Limits? (Yes or No)

YesNoUnknown

Decedent Residence – State

Decedent Residence – County

Father/Parent Name Prior to First Marriage (First, Middle, Last)

Mother/Parent Name Prior to First Marriage (First, Middle, Last)

Select the Highest Degree or Level of School completed at time of death

Circumstances of Death

Date of Death

Time of Death

Place of Death

Place of Death Address

County of Death

Death Inside City Limits? (Yes or No)

YesNoUnknown

Certifying Doctor's Name

Certifying Doctor's Phone

Doctor's Medical Facility

Medical Facility Address

Medical Facility State

Medical Facility Zip

Circumstances of Death

Manner or Death

Cause of Death

Was Positive Identity Made?

YesNoUnknown

How Was Positive ID Made?

Who Made the Positive ID?

Has the Death Certificate Been Certified?

YesNoUnknown

Next of Kin and Additional Family Contacts

Has Next of Kin Been Notified?

YesNoUnknown

If Not, Why Not?

Will Family Attend Burial?

YesNoUnknown

Burial Notice Contact Name

Burial Notice Contact Phone

Please enter UNKNOWN for all Next of Kin fields if no next of kin is known.

Next of Kin

Next of Kin's Relationship

Next of Kin's Address, City, State, Zip

Next of Kin City

Next of Kin State

Next of Kin Zip

Next of Kin Phone

Next of Kin Alt. Phone

Family Member No. 2

Family Member No. 2 Relationship

Family Member No. 2 Address

Family Member No. 2 City

Family Member No. 2 State

Family Member No. 2 Zip

Family Member No. 2 Phone

Family Member No. 2 Alt. Phone

Family Member No. 3

Family Member No. 3 Relationship

Family Member No. 3 Address

Family Member No. 3 City

Family Member No. 3 State

Family Member No. 3 Zip

Family Member No. 3 Phone

Family Member No. 3 Alt. Phone

Applicant Signature

Applicant Date Signed

Applicant Signature

Check the box to agree to the following statement:
As Applicant, I certify that to the best of my knowledge the information contained herein is true and accurate and, I a m making application for the decedent to be accepted by the Jefferson County Coroner/ Medical Examiner’s Office for county burial, to be buried at the Jefferson County Cemetery in Morris, Alabama on a date and time to be determined by Jefferson County.

County Burial Application

Applicant Information

Decedent Information

Additional Decedent Information (required for death certificate - if unknown, type UNKNOWN in field)

Circumstances of Death

Next of Kin and Additional Family Contacts

Applicant Signature